Basic Information
| Provider Information | |||||||||
| NPI: | 1639165822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIESEMER | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 COLE AVENUE | ||||||||
| Address2: | |||||||||
| City: | BISBEE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203660300 | ||||||||
| FaxNumber: | 5204322098 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 COLE AVE | ||||||||
| Address2: | |||||||||
| City: | BISBEE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856031327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204326481 | ||||||||
| FaxNumber: | 5204322098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2045 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 441486 | 05 | AZ | MEDICAID |