Provider Demographics
NPI:1871126532
Name:SERRANO, ISAAC ANDRES
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:ANDRES
Last Name:SERRANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 196
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:NM
Mailing Address - Zip Code:87567-0196
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:COUNTY RD 102 HOUES 58B
Practice Address - Street 2:
Practice Address - City:CHIMAYO
Practice Address - State:NM
Practice Address - Zip Code:87522
Practice Address - Country:US
Practice Address - Phone:505-930-1589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician