Provider Demographics
NPI:1114518016
Name:SISCO, JOSHUA R
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:R
Last Name:SISCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N MILL AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-4273
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:
Practice Address - Street 1:105 N MILL AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-4273
Practice Address - Country:US
Practice Address - Phone:479-750-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator