Basic Information
| Provider Information | |||||||||
| NPI: | 1487762753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CISNA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 S NATIONAL AVE | ||||||||
| Address2: | #540 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172692460 | ||||||||
| FaxNumber: | 4172692462 | ||||||||
| Practice Location | |||||||||
| Address1: | 10763 HIGHWAY 39 | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657127823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172692460 | ||||||||
| FaxNumber: | 4172692462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 12/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 117882 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 209273002 | 05 | MO | MEDICAID |