Provider Demographics
NPI:1215258165
Name:SISU, ANCA I (MD)
Entity type:Individual
Prefix:
First Name:ANCA
Middle Name:I
Last Name:SISU
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 1:20 S QUAKER LN STE 220
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4500
Mailing Address - Country:US
Mailing Address - Phone:703-215-2454
Mailing Address - Fax:703-828-0246
Practice Address - Street 1:20 S QUAKER LN STE 220
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4500
Practice Address - Country:US
Practice Address - Phone:703-215-2454
Practice Address - Fax:703-828-0246
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101262726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432678100Medicaid