Provider Demographics
NPI:1407368129
Name:JOSE, SISA K
Entity Type:Individual
Prefix:
First Name:SISA
Middle Name:K
Last Name:JOSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12662 TELECOM DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0935
Mailing Address - Country:US
Mailing Address - Phone:813-910-8708
Mailing Address - Fax:855-852-7153
Practice Address - Street 1:3140 S FALKENBURG RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-2574
Practice Address - Country:US
Practice Address - Phone:813-910-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9230604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8ZBR6OtherFLORIDA BLUE