Provider Demographics
NPI:1588949333
Name:COOROUGH, CARISSA ANN (PA)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANN
Last Name:COOROUGH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:ANN
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:720 S VAN BUREN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3534
Mailing Address - Country:US
Mailing Address - Phone:920-433-9400
Mailing Address - Fax:
Practice Address - Street 1:720 S VAN BUREN ST STE 301
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3534
Practice Address - Country:US
Practice Address - Phone:920-433-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2872-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant