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General NPI Number Information
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NPI Number | 1861467375
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Entity Type | Individual
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Provider Name | MANUEL SIERRA M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/19/2006
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Last Update Date | 05/28/2009
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Provider Practice Location Address
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Address Line | 1740 E 17TH ST SUITE A
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6375
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Country | US
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Telephone | 208-346-7500
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Fax |
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Provider Business Mailing Address
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Address Line | 300 VALLEYVIEW DR
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City | POCATELLO
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State | ID
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Zip | 83204-4708
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Country | US
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Telephone | 208-244-2707
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | A85395
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | M10460
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 227980
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License Number State | MA
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