Provider Demographics
NPI:1932161965
Name:BRISBIN, TAMRA (PA)
Entity Type:Individual
Prefix:
First Name:TAMRA
Middle Name:
Last Name:BRISBIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:IL
Mailing Address - Zip Code:61530-1666
Mailing Address - Country:US
Mailing Address - Phone:309-467-5000
Mailing Address - Fax:309-467-5100
Practice Address - Street 1:1932 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:IL
Practice Address - Zip Code:61530-1666
Practice Address - Country:US
Practice Address - Phone:309-467-5000
Practice Address - Fax:309-467-5100
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK12656Medicare ID - Type Unspecified
ILP01619Medicare UPIN