Basic Information
| Provider Information | |||||||||
| NPI: | 1730503855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POOLE | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIESE | ||||||||
| OtherFirstName: | MARISSA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5055 E BROADWAY BLVD | ||||||||
| Address2: | A-100 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857113640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203270460 | ||||||||
| FaxNumber: | 5207950225 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 W VALENCIA RD | ||||||||
| Address2: | SUITE #110 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857466003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207513335 | ||||||||
| FaxNumber: | 5207513312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2014 | ||||||||
| LastUpdateDate: | 02/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP5278 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.