Provider Demographics
NPI:1861467375
Name:SIERRA, MANUEL (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:SIERRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 VALLEYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4708
Mailing Address - Country:US
Mailing Address - Phone:208-244-2707
Mailing Address - Fax:
Practice Address - Street 1:1740 E 17TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6375
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-19
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA853952084P0800X
IDM104602084P0804X
MA2279802084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry