Provider Demographics
NPI:1699552109
Name:BACKHAUS, MARISSA ERIN (PA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ERIN
Last Name:BACKHAUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:MCKEEHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8450 ARISTA PL APT 316
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-4177
Mailing Address - Country:US
Mailing Address - Phone:920-562-8830
Mailing Address - Fax:
Practice Address - Street 1:302 3RD ST SE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-6419
Practice Address - Country:US
Practice Address - Phone:970-669-4855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant