MEDICARE: MS. LISA W GRESSEL MPAS, PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA0000000727	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4191422	OTHER	TN	BCBS OF TN

General Provider Information

NPI Number	:	1083763817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA W GRESSEL MPAS, PA-C

Provider Business Mailing Address
First Line	:	119 E FORT ST
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37355-1508
Country	:	US
Telephone Number	:	931-728-4477
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 E FORT ST
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37355-1508
Country	:	US
Telephone Number	:	931-728-4477
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	08/08/2011

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