Provider Demographics
NPI:1104844927
Name:MIX, CHERESSA LISETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:CHERESSA
Middle Name:LISETTE
Last Name:MIX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHERESSA
Other - Middle Name:LISETTE
Other - Last Name:RUPERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:1205 RIVER AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3724
Practice Address - Country:US
Practice Address - Phone:570-326-4118
Practice Address - Fax:570-326-5533
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002107363A00000X
PAMA051507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA364854F6KMedicare PIN