Healthcare Provider Details

I. General information

NPI: 1912963117
Provider Name (Legal Business Name): ELMER G SISNEROS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10464 S REDWOOD RD
SOUTH JORDAN UT
84095-8501
US

IV. Provider business mailing address

PO BOX 1000
DRAPER UT
84020-1000
US

V. Phone/Fax

Practice location:
  • Phone: 801-260-1919
  • Fax:
Mailing address:
  • Phone: 801-352-9500
  • Fax: 801-352-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number314098-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: