Provider Demographics
NPI:1316431380
Name:BLOSE, MARISSA VIRGINIA (PA-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:VIRGINIA
Last Name:BLOSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 TREASURE LK
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-9014
Mailing Address - Country:US
Mailing Address - Phone:814-502-4064
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1440
Practice Address - Country:US
Practice Address - Phone:814-371-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant