Provider Demographics
NPI:1770512931
Name:KONIGSBERG, ELISE FASSLER (WHCNP)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:FASSLER
Last Name:KONIGSBERG
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 N WYATT DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712
Mailing Address - Country:US
Mailing Address - Phone:520-624-1761
Mailing Address - Fax:520-622-8743
Practice Address - Street 1:1665 S LACHOLLA
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713
Practice Address - Country:US
Practice Address - Phone:520-628-3068
Practice Address - Fax:520-628-4315
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN047199363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ643925Medicaid