Provider Demographics
NPI:1013574516
Name:CISSE, IDRISSA
Entity Type:Individual
Prefix:MR
First Name:IDRISSA
Middle Name:
Last Name:CISSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:493 VALLEY STREET
Mailing Address - Street 2:APT 8
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050
Mailing Address - Country:US
Mailing Address - Phone:301-283-1954
Mailing Address - Fax:
Practice Address - Street 1:493 VALLEY STREET
Practice Address - Street 2:APT 8
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050
Practice Address - Country:US
Practice Address - Phone:301-283-1954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2019-1474343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)