Provider Demographics
NPI:1649735077
Name:TIESZEN, MATTHEW CHARLES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:CHARLES
Last Name:TIESZEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2597 RALSTON RD
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:VA
Mailing Address - Zip Code:22802-0250
Mailing Address - Country:US
Mailing Address - Phone:919-452-3336
Mailing Address - Fax:
Practice Address - Street 1:2597 RALSTON RD
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:VA
Practice Address - Zip Code:22802-0250
Practice Address - Country:US
Practice Address - Phone:919-452-3336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant