Provider Demographics
NPI:1093022519
Name:GRISSMAN, TAMARA (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:GRISSMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1284 N SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4459
Mailing Address - Country:US
Mailing Address - Phone:262-560-3700
Mailing Address - Fax:262-560-3759
Practice Address - Street 1:1284 N SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4459
Practice Address - Country:US
Practice Address - Phone:262-560-3700
Practice Address - Fax:262-560-3759
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2652-023363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical