MEDICARE: JOHNNY B SISNEROS PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	1122	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	970027495	OTHER		TRAVELERS MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	840706945058	OTHER	CO	ROCKY MOUNTAIN HEALTH PLA

General Provider Information

NPI Number	:	1093705857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNNY B SISNEROS PAC

Provider Business Mailing Address
First Line	:	106 BLANCA AVE STE 300
Second Line	:
City	:	ALAMOSA
State	:	CO
Zip	:	81101-2340
Country	:	US
Telephone Number	:	719-589-3658
Fax Number	:	719-589-0997

Provider Business Practice Location Address
First Line	:	106 BLANCA AVE STE 300
Second Line	:
City	:	ALAMOSA
State	:	CO
Zip	:	81101-2340
Country	:	US
Telephone Number	:	719-589-3658
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	02/19/2020

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Directions to “ JOHNNY B SISNEROS PAC” Practice Location

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