Provider Demographics
NPI:1114411741
Name:CISNEROS, JOSE ARMANDO (PTA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ARMANDO
Last Name:CISNEROS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 LEXINGTON GREEN LN
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1013
Mailing Address - Country:US
Mailing Address - Phone:386-801-6208
Mailing Address - Fax:
Practice Address - Street 1:1200 LEXINGTON GREEN LN
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1013
Practice Address - Country:US
Practice Address - Phone:386-801-6208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28446225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty