Basic Information
| Provider Information | |||||||||
| NPI: | 1477185171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POOTS | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | KATE | ||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BREIDER | ||||||||
| OtherFirstName: | MARISSA | ||||||||
| OtherMiddleName: | KATE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2723 WILLIAMS DR | ||||||||
| Address2: | |||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505017131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127198104 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1428 2ND AVE N | ||||||||
| Address2: | |||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505014119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155746110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2020 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.