Provider Demographics
NPI:1861200362
Name:SISCO, TERRANCE
Entity type:Individual
Prefix:
First Name:TERRANCE
Middle Name:
Last Name:SISCO
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 1:9580 OAK AVENUE PKWY STE 7-162
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-1888
Mailing Address - Country:US
Mailing Address - Phone:714-322-1344
Mailing Address - Fax:
Practice Address - Street 1:9580 OAK AVENUE PKWY STE 7-162
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-1888
Practice Address - Country:US
Practice Address - Phone:714-322-1344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC4267060172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver