Healthcare Provider Details

I. General information

NPI: 1164840617
Provider Name (Legal Business Name): THERESA MACDISSI P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EDMUNDSON PL STE 306
COUNCIL BLUFFS IA
51503
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 712-396-7787
  • Fax: 712-396-4115
Mailing address:
  • Phone: 402-354-2100
  • Fax: 402-354-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number092083
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1802
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: