Provider Demographics
NPI:1578244323
Name:ENRIQUE, ELYSSA M (PA-C)
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:M
Last Name:ENRIQUE
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 1:613 ROYER AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-2457
Mailing Address - Country:US
Mailing Address - Phone:330-313-4114
Mailing Address - Fax:
Practice Address - Street 1:4501 EMPIRE CT
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-1949
Practice Address - Country:US
Practice Address - Phone:540-371-0079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant