Provider Demographics
NPI:1538584750
Name:MICHAELA R SISNEROS
Entity type:Organization
Organization Name:MICHAELA R SISNEROS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN - NURSE
Authorized Official - Prefix:
Authorized Official - First Name:MICHAELA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:SISNEROS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:307-851-3184
Mailing Address - Street 1:2890 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-8903
Mailing Address - Country:US
Mailing Address - Phone:307-851-3184
Mailing Address - Fax:307-332-0131
Practice Address - Street 1:2890 COOPER RD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-851-3184
Practice Address - Fax:307-332-0131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY30961251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY105726000Medicaid