Provider Demographics
NPI:1699717181
Name:SISSON, CHARLES BRADLEY (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BRADLEY
Last Name:SISSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2244 E HARMONY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3422
Mailing Address - Country:US
Mailing Address - Phone:970-412-5928
Mailing Address - Fax:970-632-6181
Practice Address - Street 1:2244 E HARMONY RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3422
Practice Address - Country:US
Practice Address - Phone:970-412-5928
Practice Address - Fax:970-632-6181
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35700207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42708877Medicaid
F51486Medicare UPIN
CO448848Medicare ID - Type Unspecified