Healthcare Provider Details

I. General information

NPI: 1356025159
Provider Name (Legal Business Name): IAN CISSEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 VARNUM AVE
LOWELL MA
01854-2134
US

IV. Provider business mailing address

200 WOODVIEW WAY APT 2306
ANDOVER MA
01810-4592
US

V. Phone/Fax

Practice location:
  • Phone: 978-937-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: