Provider Demographics
NPI:1184166779
Name:WILSON CISNERO, TAMARA (MD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:WILSON CISNERO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 CALLE SANTA CRUZ APT 7A
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961-6926
Mailing Address - Country:US
Mailing Address - Phone:585-472-1766
Mailing Address - Fax:
Practice Address - Street 1:1741 E NINE MILE RD STE 5
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5478
Practice Address - Country:US
Practice Address - Phone:850-462-9387
Practice Address - Fax:850-462-9389
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR023999208D00000X
FLACN1676208D00000X
NYP04324208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice