Provider Demographics
NPI:1144786237
Name:GOOLSBY, MARISSA WEICHING (PA-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:WEICHING
Last Name:GOOLSBY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:WEICHING-GOOLSBY
Other - Last Name:ACUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2476 RIDGEFIELD TER
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4211
Mailing Address - Country:US
Mailing Address - Phone:904-347-8711
Mailing Address - Fax:
Practice Address - Street 1:4650 HUGH HOWELL RD STE 510
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5031
Practice Address - Country:US
Practice Address - Phone:678-956-8630
Practice Address - Fax:678-956-8634
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 390200000X
GA11151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program