Provider Demographics
NPI:1356762470
Name:CISCO, STEVEN (DPT)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:CISCO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14028 SE PETROVITSKY RD
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-8933
Mailing Address - Country:US
Mailing Address - Phone:425-272-0252
Mailing Address - Fax:
Practice Address - Street 1:14028 SE PETROVITSKY RD
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8933
Practice Address - Country:US
Practice Address - Phone:425-272-0252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60386590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1356762470Medicaid
WA1356762470Medicaid