Provider Demographics
NPI:1831102425
Name:TISSOT, JOHN EDWARD (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:TISSOT
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 1:2193 HUMMINGBIRD LN
Mailing Address - Street 2:109 BEE ST CHARLESTON,S.C RALPH H. JOHNSON VA HOSP
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-2345
Mailing Address - Country:US
Mailing Address - Phone:843-789-7073
Mailing Address - Fax:843-789-7155
Practice Address - Street 1:2193 HUMMINGBIRD LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-2345
Practice Address - Country:US
Practice Address - Phone:843-871-2108
Practice Address - Fax:843-789-7155
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA356363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical