Basic Information
| Provider Information | |||||||||
| NPI: | 1104844927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIX | ||||||||
| FirstName: | CHERESSA | ||||||||
| MiddleName: | LISETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUPERT | ||||||||
| OtherFirstName: | CHERESSA | ||||||||
| OtherMiddleName: | LISETTE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7 DOCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178428910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708372123 | ||||||||
| FaxNumber: | 5708372185 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 RIVER AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177013724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703264118 | ||||||||
| FaxNumber: | 5703265533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 01/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OA002107 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA051507 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.