Provider Demographics
NPI:1659896892
Name:BLACK, ELISSA MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:MICHELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:MICHELLE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8200
Mailing Address - Fax:
Practice Address - Street 1:15812 E INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1875
Practice Address - Country:US
Practice Address - Phone:509-444-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61588597363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant