Basic Information
| Provider Information | |||||||||
| NPI: | 1659691491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAGE | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KANTHAL | ||||||||
| OtherFirstName: | MARISSA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182130478 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 2388 ROUTE 9 STE 103 | ||||||||
| Address2: | |||||||||
| City: | MECHANICVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121183433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823899 | ||||||||
| FaxNumber: | 5187823884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2010 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F336183 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03273750 | 05 | NY | MEDICAID |