Provider Demographics
NPI:1619517810
Name:BRIVCHIK, DORISSA LEA (PA-C)
Entity Type:Individual
Prefix:
First Name:DORISSA
Middle Name:LEA
Last Name:BRIVCHIK
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:5500 CORPORATE DR STE 320
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-5848
Practice Address - Country:US
Practice Address - Phone:412-435-1170
Practice Address - Fax:412-435-1171
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
15002512OtherCAQH
PA103837118Medicaid