Provider Demographics
NPI:1740996149
Name:SISNEROS, SHAYE (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:SHAYE
Middle Name:
Last Name:SISNEROS
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 GRAND ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1816
Mailing Address - Country:US
Mailing Address - Phone:308-529-3509
Mailing Address - Fax:
Practice Address - Street 1:9201 E MOUNTAIN VIEW RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5199
Practice Address - Country:US
Practice Address - Phone:877-564-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2494733163WM0705X
MN9215363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical