Healthcare Provider Details

I. General information

NPI: 1093705857
Provider Name (Legal Business Name): JOHNNY B SISNEROS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 BLANCA AVE STE 300
ALAMOSA CO
81101-2340
US

IV. Provider business mailing address

106 BLANCA AVE STE 300
ALAMOSA CO
81101-2340
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-3658
  • Fax:
Mailing address:
  • Phone: 719-589-3658
  • Fax: 719-589-0997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1122
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: