Healthcare Provider Details

I. General information

NPI: 1649735077
Provider Name (Legal Business Name): MATTHEW CHARLES TIESZEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 JAHNKE RD STE 280
RICHMOND VA
23225-4017
US

IV. Provider business mailing address

116 S DAVIS AVE APT 5115
RICHMOND VA
23220-5159
US

V. Phone/Fax

Practice location:
  • Phone: 804-716-7758
  • Fax: 804-918-8664
Mailing address:
  • Phone: 919-452-3336
  • 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: