Provider Demographics
NPI:1639165822
Name:GRIESEMER, KATHY (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:GRIESEMER
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 1:101 COLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603
Mailing Address - Country:US
Mailing Address - Phone:520-366-0300
Mailing Address - Fax:520-432-2098
Practice Address - Street 1:101 COLE AVE
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603-1327
Practice Address - Country:US
Practice Address - Phone:520-432-6481
Practice Address - Fax:520-432-2098
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ441486Medicaid
25378Medicare ID - Type Unspecified
AZ441486Medicaid