Provider Demographics
NPI:1558566455
Name:TISCH, MARY C (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:TISCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2901 TELESTAR CT.
Mailing Address - Street 2:#300
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1263
Mailing Address - Country:US
Mailing Address - Phone:703-591-1688
Mailing Address - Fax:703-591-1445
Practice Address - Street 1:3580 JOSEPH SIEWICK DR STE 305
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1764
Practice Address - Country:US
Practice Address - Phone:703-648-3266
Practice Address - Fax:703-648-3264
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003594363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1558566445Medicaid
VAVV4205BMedicare PIN
DC295525ZC3UMedicare PIN