Provider Demographics
NPI:1780721753
Name:GARCIA FAUST, MARISA S (PA C)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:S
Last Name:GARCIA FAUST
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 MARYLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218
Mailing Address - Country:US
Mailing Address - Phone:410-467-6040
Mailing Address - Fax:410-735-5898
Practice Address - Street 1:8341 PIONEER DRIVE
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144
Practice Address - Country:US
Practice Address - Phone:410-467-6040
Practice Address - Fax:410-735-5898
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S93133Medicare UPIN