Provider Demographics
NPI:1093705857
Name:SISNEROS, JOHNNY B (PAC)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:B
Last Name:SISNEROS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 BLANCA AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2340
Mailing Address - Country:US
Mailing Address - Phone:719-589-3658
Mailing Address - Fax:719-589-0997
Practice Address - Street 1:106 BLANCA AVE STE 300
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2340
Practice Address - Country:US
Practice Address - Phone:719-589-3658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1122363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840706945058OtherROCKY MOUNTAIN HEALTH PLA
970027495OtherTRAVELERS MEDICARE
CO840706945058OtherROCKY MOUNTAIN HEALTH PLA