Provider Demographics
NPI:1700544103
Name:SISOFO, NICHOLAS THOMAS IV (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:THOMAS
Last Name:SISOFO
Suffix:IV
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 OLD TROLLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-5203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:709 OLD TROLLEY RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5203
Practice Address - Country:US
Practice Address - Phone:843-900-6767
Practice Address - Fax:843-285-5916
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5185PAMedicaid