Provider Demographics
NPI:1811214349
Name:GRIESACKER, PAULA
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:GRIESACKER
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 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:
Practice Address - Street 1:354 CRAIG ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-2710
Practice Address - Country:US
Practice Address - Phone:814-746-0645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN323432L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA185166VKCMedicare UPIN