Provider Demographics
NPI:1548752496
Name:SISSON, MARIAH NICOLE
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:NICOLE
Last Name:SISSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-384-6440
Mailing Address - Fax:319-384-6295
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-384-6440
Practice Address - Fax:319-384-6295
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN72349208000000X, 2080S0010X
IAMD-536542080S0010X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine