Basic Information
| Provider Information | |||||||||
| NPI: | 1518588326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CISNEROS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RT (R) | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CISNEROS | ||||||||
| OtherFirstName: | JESSICA | ||||||||
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| OtherCredential: | RT (R) | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 70 PERIMETER CTR E APT 1438 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303461828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066180106 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 JOHNSON FERRY RD | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048518000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2020 | ||||||||
| LastUpdateDate: | 05/03/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 576116 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.