Healthcare Provider Details

I. General information

NPI: 1629794052
Provider Name (Legal Business Name): KAITLIN NICOLE SISSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W BEN WHITE BLVD STE 200
AUSTIN TX
78704-7192
US

IV. Provider business mailing address

205 E UNIVERSITY AVE STE 200
GEORGETOWN TX
78626-6821
US

V. Phone/Fax

Practice location:
  • Phone: 877-800-5722
  • Fax:
Mailing address:
  • Phone: 512-994-1933
  • 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: