Provider Demographics
NPI:1962054304
Name:SUHOCKI, MARISSA ROSE
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ROSE
Last Name:SUHOCKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 AIRPORT DR
Mailing Address - Street 2:STE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-2289
Mailing Address - Country:US
Mailing Address - Phone:614-859-1900
Mailing Address - Fax:614-645-5517
Practice Address - Street 1:1180 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1902
Practice Address - Country:US
Practice Address - Phone:614-645-5535
Practice Address - Fax:614-645-5517
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH025012363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH025012Medicaid