Provider Demographics
NPI:1386887727
Name:FAIRCLOTH, MARISA SCARLETT (PA-C)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:SCARLETT
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:SCARLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1226
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37065-1226
Mailing Address - Country:US
Mailing Address - Phone:615-591-2732
Mailing Address - Fax:615-591-2779
Practice Address - Street 1:1419 NATIONAL HWY
Practice Address - Street 2:MIDWAY PLAZA
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-2319
Practice Address - Country:US
Practice Address - Phone:336-889-7213
Practice Address - Fax:336-889-7216
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant