Provider Demographics
NPI:1588317259
Name:O'CONNOR, MARISSA LOREN (PA-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LOREN
Last Name:O'CONNOR
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 1:18 DAMIN CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-1604
Mailing Address - Country:US
Mailing Address - Phone:631-617-2558
Mailing Address - Fax:
Practice Address - Street 1:18 DAMIN CIR
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-1604
Practice Address - Country:US
Practice Address - Phone:631-617-2558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant