Provider Demographics
NPI:1083437917
Name:ROBESON, MARISSA MAY (PA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:MAY
Last Name:ROBESON
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 1:16838 SILVERADO DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-3934
Mailing Address - Country:US
Mailing Address - Phone:734-307-6656
Mailing Address - Fax:
Practice Address - Street 1:400 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2136
Practice Address - Country:US
Practice Address - Phone:877-929-6342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant