Provider Demographics
NPI:1184717357
Name:RIESS, JILL ANN (PA-C)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:ANN
Last Name:RIESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2912 SPRINGBORO W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1674
Mailing Address - Country:US
Mailing Address - Phone:937-297-8996
Mailing Address - Fax:
Practice Address - Street 1:70 REMICK BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9168
Practice Address - Country:US
Practice Address - Phone:937-885-0701
Practice Address - Fax:937-885-0702
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-000420363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant