MEDICARE: CARISSA ANN COOROUGH PA

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	363A00000X	Physician Assistant	2872-23	WI

General Provider Information

NPI Number	:	1588949333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARISSA ANN COOROUGH PA

Provider Business Mailing Address
First Line	:	720 S VAN BUREN ST STE 301
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-3534
Country	:	US
Telephone Number	:	920-433-9400
Fax Number	:

Provider Business Practice Location Address
First Line	:	720 S VAN BUREN ST STE 301
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-3534
Country	:	US
Telephone Number	:	920-433-9400
Fax Number	:

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

Provider Enumeration Date	:	10/12/2011
Last Update Date	:	07/11/2018

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Directions to “ CARISSA ANN COOROUGH PA” Practice Location

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