Provider Demographics
NPI:1982812541
Name:SISON, MALCOLM (PT)
Entity Type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:
Last Name:SISON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5307 CAMERON LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-7584
Mailing Address - Country:US
Mailing Address - Phone:765-447-7454
Mailing Address - Fax:
Practice Address - Street 1:3401 SOLDIERS HOME RD
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE BRA
Practice Address - State:IN
Practice Address - Zip Code:47906-1222
Practice Address - Country:US
Practice Address - Phone:654-463-1541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008873A313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility