Provider Demographics
NPI:1053591073
Name:ABBOTT, MARISA SHANA (DC)
Entity type:Individual
Prefix:DR
First Name:MARISA
Middle Name:SHANA
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:MONESSEN
Mailing Address - State:PA
Mailing Address - Zip Code:15062-2240
Mailing Address - Country:US
Mailing Address - Phone:724-684-8810
Mailing Address - Fax:724-684-8856
Practice Address - Street 1:1725 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:MONESSEN
Practice Address - State:PA
Practice Address - Zip Code:15062-2240
Practice Address - Country:US
Practice Address - Phone:724-684-8810
Practice Address - Fax:724-684-8856
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009183111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA077384Medicare PIN
PAU99170Medicare UPIN