Healthcare Provider Details

I. General information

NPI: 1104844927
Provider Name (Legal Business Name): CHERESSA LISETTE MIX PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHERESSA LISETTE RUPERT PA-C

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 01/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 RIVER AVE 2ND FLOOR
WILLIAMSPORT PA
17701-3724
US

IV. Provider business mailing address

7 DOCK HILL RD
MIDDLEBURG PA
17842-8910
US

V. Phone/Fax

Practice location:
  • Phone: 570-326-4118
  • Fax: 570-326-5533
Mailing address:
  • Phone: 570-837-2123
  • Fax: 570-837-2185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA002107
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA051507
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: