Provider Demographics
NPI:1952911349
Name:FIDLER, MARISSA LEE (PA-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LEE
Last Name:FIDLER
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 1:370 W HIGHLANDS DR STE 240
Mailing Address - Street 2:
Mailing Address - City:EAST ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-7745
Mailing Address - Country:US
Mailing Address - Phone:706-635-1400
Mailing Address - Fax:
Practice Address - Street 1:370 W HIGHLANDS DR STE 240
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-7745
Practice Address - Country:US
Practice Address - Phone:706-635-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant