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General NPI Number Information
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NPI Number | 1164840617
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Entity Type | Individual
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Provider Name | THERESA MACDISSI P.A.-C
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Gender | Female
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Dates
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Enumeration Date | 04/02/2014
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Last Update Date | 06/18/2018
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Provider Practice Location Address
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Address Line | 1 EDMUNDSON PL STE 306
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51503
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Country | US
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Telephone | 712-396-7787
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Fax | 712-396-4115
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Provider Business Mailing Address
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Address Line | PO BOX 3755
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City | OMAHA
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State | NE
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Zip | 68103-0755
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Country | US
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Telephone | 402-354-2100
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Fax | 402-354-2155
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 1802
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 092083
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License Number State | IA
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