Individual
THERESA MACDISSI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.-C
Contact information
Practice address
1 EDMUNDSON PL STE 306, COUNCIL BLUFFS, IA 51503
(712) 396-7787
(712) 396-4115
Mailing address
PO BOX 3755, OMAHA, NE 68103-0755
(402) 354-2100
(402) 354-2155
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
092083
IA
363AM0700X
Medical Physician Assistant
1802
NE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1164840617
—
IA
05
—
47068731713
—
NE
Enumeration date
04/02/2014
Last updated
06/18/2018
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