Marissa Jacqueline Wagner Edmunds, PA-C
Physician Assistant in Fort Collins, CO. Individual provider (NPI-1).
NPI number1104657261
StatusActive
Last updated in NPPESOct 30, 2026
Details
- NPI
- 1104657261
- Entity type
- Individual (NPI-1)
- Name
- Marissa Jacqueline Wagner Edmunds
- Credential
- PA-C
- Sex
- Female
- Sole proprietor
- No
- Enumeration date
- Aug 12, 2024
- Certification date
- Oct 30, 2026
- Last updated
- Oct 30, 2026
Medicare and OIG
- Medicare enrolled (PECOS)
- Not in the Medicare enrollment file
- Can order and refer
- Not on the CMS order and referring list
- OIG exclusion list
- This NPI is not listed
CMS and OIG files of November 2026. PECOS lookup · OIG exclusion check
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 363A00000X | Physician Assistant | PA.0010167 | CO | Yes |
| 207Q00000X | Family Medicine | PA.0010167 | CO |
Practice location
702a W Drake RdFort Collins, CO 80526-5521
Phone 970-821-4600
Mailing address
702a W Drake RdFort Collins, CO 80526-5521
Phone 970-821-4600
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