Provider Demographics
NPI:1942333745
Name:RISSACHER, PATTY (MD)
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:
Last Name:RISSACHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATTY
Other - Middle Name:
Other - Last Name:WATERHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:80 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1450
Practice Address - Country:US
Practice Address - Phone:315-261-7180
Practice Address - Fax:315-261-7183
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0011547208000000X
NY266529208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1015060Medicaid
NY02981991Medicare PIN
VT000589001Medicare PIN
VTOTH000Medicare UPIN