Basic Information
| Provider Information | |||||||||
| NPI: | 1891104261 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBBINS | ||||||||
| FirstName: | MARISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KINGS HWY S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146175504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859220553 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1445 PORTLAND AVE | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859222906 | ||||||||
| FaxNumber: | 5859222951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2014 | ||||||||
| LastUpdateDate: | 04/01/2019 | ||||||||
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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 | 363A00000X | 017797 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 03974738 | 05 | NY | MEDICAID |