Healthcare Provider Details

I. General information

NPI: 1073452967
Provider Name (Legal Business Name): ELISE RACHEL MARCUSSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 GRACIE PL
GOLDSBORO NC
27534-2260
US

IV. Provider business mailing address

4701 SOUTHWESTERN BLVD APT C6
HAMBURG NY
14075-1872
US

V. Phone/Fax

Practice location:
  • Phone: 919-735-1635
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001016422
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: