Healthcare Provider Details

I. General information

NPI: 1275817934
Provider Name (Legal Business Name): MATTHEW ALLEN CISSELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 01/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-8711
  • Fax:
Mailing address:
  • Phone: 703-776-8711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110-004585
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0004795
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1102319
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: