Provider Demographics
NPI:1043876170
Name:DISSELKAMP, MARY ALICE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:DISSELKAMP
Suffix:
Gender:F
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:2407 RING RD STE 108
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-5938
Mailing Address - Country:US
Mailing Address - Phone:270-706-5787
Mailing Address - Fax:270-706-5788
Practice Address - Street 1:2407 RING RD STE 108
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-5938
Practice Address - Country:US
Practice Address - Phone:270-706-5787
Practice Address - Fax:270-706-5788
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2023-11-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant