Healthcare Provider Details

I. General information

NPI: 1033427240
Provider Name (Legal Business Name): BETHLEHEM SISAY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

2024 GEORGIA AVE NW
WASHINGTON DC
20001-3027
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-8013
  • Fax:
Mailing address:
  • Phone: 202-595-3223
  • Fax: 202-332-0028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA030680
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: