1457375032 NPI number — MARISSA ANN EDWARDS P.A.C.

Table of content: MARISSA ANN EDWARDS P.A.C. (NPI 1457375032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457375032 NPI number — MARISSA ANN EDWARDS P.A.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDWARDS
Provider First Name:
MARISSA
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLYER
Provider Other First Name:
MARISSA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.A.C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457375032
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
899 POPLAR CHURCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMP HILL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17011-2206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
177-630-4307
Provider Business Mailing Address Fax Number:
717-763-9854

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
899 POPLAR CHURCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMP HILL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17011-2206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-763-0430
Provider Business Practice Location Address Fax Number:
717-763-9854
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  MA060596 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1036509320004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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