Provider Demographics
NPI:1710111844
Name:SIRA, ANCA MARISSA (LAC, FABORM)
Entity Type:Individual
Prefix:
First Name:ANCA
Middle Name:MARISSA
Last Name:SIRA
Suffix:
Gender:F
Credentials:LAC, FABORM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-0959
Mailing Address - Country:US
Mailing Address - Phone:628-888-4881
Mailing Address - Fax:530-686-7952
Practice Address - Street 1:432 N MOUNT SHASTA BLVD STE A
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2910
Practice Address - Country:US
Practice Address - Phone:628-888-4881
Practice Address - Fax:530-686-7952
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6952171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist