Provider Demographics
NPI:1780979971
Name:GARDNER, MARISA (PA-C)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:WORTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1293 E PARKDALE AVE STE 2300B
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-8989
Mailing Address - Country:US
Mailing Address - Phone:231-398-1735
Mailing Address - Fax:
Practice Address - Street 1:1293 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660
Practice Address - Country:US
Practice Address - Phone:231-398-1735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108031363A00000X
MI5601006014363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant