Basic Information
| Provider Information | |||||||||
| NPI: | 1467014472 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA -C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2570 ROUTE 9W STE 10 | ||||||||
| Address2: | |||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452203100 | ||||||||
| FaxNumber: | 8455342940 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 OLD FIRE HOUSE RD | ||||||||
| Address2: | |||||||||
| City: | WALLKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125894600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453936015 | ||||||||
| FaxNumber: | 8453936016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2019 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 023906 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.