Individual
MARK NACIANCENO DE FIESTA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
326 COUNTRY CLUB DR, NEW ALBANY, IN 47150
(812) 948-1311
Mailing address
105 ORCHARD HILLS DR APT 92, JEFFERSONVILLE, IN 47130-8281
(407) 773-5523
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
OJH016M89073
BLUECROSSBLUESHIELD
GA
Enumeration date
05/14/2018
Last updated
05/14/2018
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