Healthcare Provider Details

I. General information

NPI: 1881230647
Provider Name (Legal Business Name): NOEL A CISNEROS AT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S 6TH AVE
YAKIMA WA
98902-3303
US

IV. Provider business mailing address

2503 CLINTON WAY
YAKIMA WA
98902-5135
US

V. Phone/Fax

Practice location:
  • Phone: 509-573-2728
  • Fax:
Mailing address:
  • Phone: 509-969-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number60047736
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: