Provider Demographics
NPI:1912528027
Name:RIESE, MACEY A
Entity Type:Individual
Prefix:
First Name:MACEY
Middle Name:A
Last Name:RIESE
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 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:6438 WILMINGTON PIKE STE 100
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-7021
Practice Address - Country:US
Practice Address - Phone:937-558-3840
Practice Address - Fax:937-558-3844
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant