Provider Demographics
NPI:1558686345
Name:MATTIS, FALLON ANDREA (MD)
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:ANDREA
Last Name:MATTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-2511
Mailing Address - Country:US
Mailing Address - Phone:646-835-9001
Mailing Address - Fax:
Practice Address - Street 1:101 AUBREYS LOOP
Practice Address - Street 2:SENTARA HALIFAX FAMILY MEDICINE
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-5054
Practice Address - Country:US
Practice Address - Phone:646-835-9001
Practice Address - Fax:646-835-9001
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR7061207Q00000X
MN63188207Q00000X
IL036144488207Q00000X
MO2017034134207Q00000X
UT10501937-1205207Q00000X
NY273617-1207Q00000X
NJ25MA10713600207Q00000X
VA0101257845207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1558686345OtherFAMILY MEDICINE