Provider Demographics
NPI:1790245884
Name:MASTROCOLA, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MASTROCOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 BROADWAY ST # MC6342
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-3132
Mailing Address - Country:US
Mailing Address - Phone:650-721-1836
Mailing Address - Fax:
Practice Address - Street 1:450 BROADWAY ST # MC6342
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3132
Practice Address - Country:US
Practice Address - Phone:650-721-1836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-23
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program