Provider Demographics
NPI:1326661513
Name:RAYMOND, CHARISSA
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:
Last Name:RAYMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:521 E SIOUX AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3142
Practice Address - Country:US
Practice Address - Phone:605-945-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SD0572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program