Provider Demographics
NPI:1881894814
Name:FISTOLA, MARISSA J (PA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:J
Last Name:FISTOLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ASYLUM AVE
Mailing Address - Street 2:SUITE 3212
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1770
Mailing Address - Country:US
Mailing Address - Phone:860-522-1171
Mailing Address - Fax:860-493-6524
Practice Address - Street 1:1000 ASYLUM AVE
Practice Address - Street 2:SUITE 3212
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1770
Practice Address - Country:US
Practice Address - Phone:860-522-1171
Practice Address - Fax:860-493-6524
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001926363A00000X
CT0019267363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical