Basic Information
| Provider Information | |||||||||
| NPI: | 1053586255 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERRERA | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BARCO | ||||||||
| OtherFirstName: | MARISA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10767 E TRAVERSE HWY | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496846219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319471112 | ||||||||
| FaxNumber: | 2319477739 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494551243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318612130 | ||||||||
| FaxNumber: | 2318614964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2008 | ||||||||
| LastUpdateDate: | 10/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704233226 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.