Provider Demographics
NPI:1336633585
Name:CISNEROS, JULIAN (OTA)
Entity Type:Individual
Prefix:
First Name:JULIAN
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 EUBANK BLVD NE APT 9
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6180
Mailing Address - Country:US
Mailing Address - Phone:757-773-2922
Mailing Address - Fax:
Practice Address - Street 1:5801 EUBANK BLVD NE APT 9
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-6180
Practice Address - Country:US
Practice Address - Phone:757-773-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3889224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant