Provider Demographics
NPI:1134789878
Name:SANJURJO, TRINISHA
Entity type:Individual
Prefix:
First Name:TRINISHA
Middle Name:
Last Name:SANJURJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 JAMES ST STE 211
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-2238
Mailing Address - Country:US
Mailing Address - Phone:315-796-6666
Mailing Address - Fax:
Practice Address - Street 1:2817 JAMES ST STE 211
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13206-2238
Practice Address - Country:US
Practice Address - Phone:315-796-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20-1302Y10405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY84-2101439Medicaid