Provider Demographics
NPI:1912166786
Name:DELISSER, KEMESHA (MD)
Entity type:Individual
Prefix:DR
First Name:KEMESHA
Middle Name:
Last Name:DELISSER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 SUNRISE AVE STE 602
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4542
Mailing Address - Country:US
Mailing Address - Phone:916-953-7571
Mailing Address - Fax:916-771-8515
Practice Address - Street 1:480 DEL NORTE AVE
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-4125
Practice Address - Country:US
Practice Address - Phone:916-953-7571
Practice Address - Fax:916-771-8515
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252058208100000X, 208VP0014X
WAMD60960761208VP0014X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2137088Medicaid