Provider Demographics
NPI:1427712736
Name:TISS, MATTHEW JOHN (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:TISS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 WEEOT WAY
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4734
Mailing Address - Country:US
Mailing Address - Phone:707-825-5000
Mailing Address - Fax:707-825-6747
Practice Address - Street 1:434 7TH ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1803
Practice Address - Country:US
Practice Address - Phone:707-296-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047801225100000X
CA302089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist