Basic Information
| Provider Information | |||||||||
| NPI: | 1679047708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADLESICH | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERTOLONE-SMITH | ||||||||
| OtherFirstName: | MARISA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 311 SW 2ND ST | ||||||||
| Address2: | # 2546 | ||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973334631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032017064 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2801 PURCELL ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806013551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036599700 | ||||||||
| FaxNumber: | 3035588222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2019 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2314 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA.0006105 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA203098 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.