Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208G00000X | Cardiothoracic Vascular Surgeon | 95012716 | CA |
NPI | 1134779861 |
---|---|
Provider Name | Jacqueline Ann Sisto |
First Address | Los Angeles, CA 90035-3457 |
Second Address | Durham, NC 27710-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/09/2019 |
Last Update Date | 14/09/2019 |