Healthcare Provider Details

I. General information

NPI: 1255589024
Provider Name (Legal Business Name): JUAN A SIERRA VEGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA 110 KM 20 0 BO CENTRO
MOCA PR
00676
US

IV. Provider business mailing address

PO BOX 1777
ISABELA PR
00662
US

V. Phone/Fax

Practice location:
  • Phone: 787-882-2371
  • Fax:
Mailing address:
  • Phone: 787-882-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License NumberTC AMB 402
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: