Basic Information
| Provider Information | |||||||||
| NPI: | 1407368129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOSE | ||||||||
| FirstName: | SISA | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12662 TELECOM DR | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139108708 | ||||||||
| FaxNumber: | 8558527153 | ||||||||
| Practice Location | |||||||||
| Address1: | 3140 S FALKENBURG RD | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335782574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139100300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2017 | ||||||||
| LastUpdateDate: | 12/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 9230604 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 8ZBR6 | 01 | FL | FLORIDA BLUE | OTHER |