Provider Demographics
NPI:1689294084
Name:SIEBRASSE, ALISA
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:SIEBRASSE
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 1:102 MASON FARM RD
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-4617
Mailing Address - Country:US
Mailing Address - Phone:984-974-4462
Mailing Address - Fax:919-843-9355
Practice Address - Street 1:102 MASON FARM RD
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4617
Practice Address - Country:US
Practice Address - Phone:984-974-4462
Practice Address - Fax:919-843-9355
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-26
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261474390200000X
NC2023-00405207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program