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General NPI Number Information
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NPI Number | 1649735077
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Entity Type | Individual
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Provider Name | MATTHEW CHARLES TIESZEN PA-C
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Gender | Male
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Dates
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Enumeration Date | 02/11/2019
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Last Update Date | 11/19/2024
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Provider Practice Location Address
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Address Line | 7101 JAHNKE RD STE 280
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City | RICHMOND
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State | VA
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Zip | 23225-4017
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Country | US
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Telephone | 804-716-7758
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Fax | 804-918-8664
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Provider Business Mailing Address
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Address Line | 116 S DAVIS AVE APT 5115
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City | RICHMOND
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State | VA
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Zip | 23220-5159
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Country | US
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Telephone | 919-452-3336
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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