Provider Demographics
NPI:1497217400
Name:WISSEKERKE, LIBBI (PA-C)
Entity Type:Individual
Prefix:
First Name:LIBBI
Middle Name:
Last Name:WISSEKERKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LIBBI
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-4161
Practice Address - Fax:508-856-6703
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01129363A00000X
MAPA8171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant