Healthcare Provider Details

I. General information

NPI: 1114411741
Provider Name (Legal Business Name): JOSE ARMANDO CISNEROS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 LEXINGTON GREEN LN
SANFORD FL
32771-1013
US

IV. Provider business mailing address

1200 LEXINGTON GREEN LN
SANFORD FL
32771-1013
US

V. Phone/Fax

Practice location:
  • Phone: 386-801-6208
  • Fax:
Mailing address:
  • Phone: 386-801-6208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number28446
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: