Provider Demographics
NPI:1376429241
Name:MEZZATESTA, MARISSA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ROSE
Last Name:MEZZATESTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 W MISTY WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3960
Mailing Address - Country:US
Mailing Address - Phone:602-405-8375
Mailing Address - Fax:
Practice Address - Street 1:4408 W MISTY WILLOW LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-3960
Practice Address - Country:US
Practice Address - Phone:602-405-8375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical