Provider Demographics
NPI:1790343739
Name:CISNEROS, RAFAEL
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:CISNEROS
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 1:11820 W 100TH TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-2441
Mailing Address - Country:US
Mailing Address - Phone:913-953-1220
Mailing Address - Fax:
Practice Address - Street 1:377 NW JASPER ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1279
Practice Address - Country:US
Practice Address - Phone:913-953-1220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018026092225200000X
ORCP000275A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant