Provider Demographics
NPI:1982108437
Name:SISNEROS, ISIAH SISNEROS EDWARD
Entity Type:Individual
Prefix:
First Name:ISIAH SISNEROS
Middle Name:EDWARD
Last Name:SISNEROS
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 1:155 S ARGYLE AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-4405
Mailing Address - Country:US
Mailing Address - Phone:916-729-3008
Mailing Address - Fax:916-780-0118
Practice Address - Street 1:7339 N 1ST ST STE 105&110
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2954
Practice Address - Country:US
Practice Address - Phone:916-729-3006
Practice Address - Fax:916-780-0119
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4322Medicaid