Basic Information
| Provider Information | |||||||||
| NPI: | 1023644671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAAS | ||||||||
| FirstName: | MARISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 EASTLAKE AVE STE 7416 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900891020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238653700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1441 EASTLAKE AVE STE 7416 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900891020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238653700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2020 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208800000X | PTL6115 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | N/A | OTHER |