Provider Demographics
NPI:1215476122
Name:GINGERICH, TESSA MIRANN (PA)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:MIRANN
Last Name:GINGERICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TESSA
Other - Middle Name:M
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:912B STATE HIGHWAY 59
Mailing Address - Street 2:
Mailing Address - City:GOODMAN
Mailing Address - State:MO
Mailing Address - Zip Code:64843-8252
Mailing Address - Country:US
Mailing Address - Phone:417-364-8300
Mailing Address - Fax:417-364-7290
Practice Address - Street 1:912B STATE HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:GOODMAN
Practice Address - State:MO
Practice Address - Zip Code:64843-8252
Practice Address - Country:US
Practice Address - Phone:417-364-8300
Practice Address - Fax:417-364-7290
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017002400363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical