Healthcare Provider Details

I. General information

NPI: 1639165822
Provider Name (Legal Business Name): KATHY GRIESEMER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 08/12/2022
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 COLE AVE
BISBEE AZ
85603-1327
US

IV. Provider business mailing address

101 COLE AVENUE
BISBEE AZ
85603
US

V. Phone/Fax

Practice location:
  • Phone: 520-432-6481
  • Fax: 520-432-2098
Mailing address:
  • Phone: 520-366-0300
  • Fax: 520-432-2098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2045
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: