Kenneth Lee Sisco, M.D.

Primary specialty

Anatomic Pathology & Clinical Pathology PhysicianTaxonomy code 207ZP0102X

License

63928 Issued in AZ

Practice address

36386 N Secret Garden Path
San Tan Valley, AZ 85140-5434

Phone

(732) 673-7050

NPI assigned

Apr 3, 2007

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MD

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175558400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1686787200000",
    "number": "1003937111",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "36386 N SECRET GARDEN PATH",
            "city": "SAN TAN VALLEY",
            "state": "AZ",
            "postal_code": "851405434",
            "telephone_number": "732-673-7050"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "36386 N SECRET GARDEN PATH",
            "city": "SAN TAN VALLEY",
            "state": "AZ",
            "postal_code": "851405434",
            "telephone_number": "732-673-7050"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SISCO",
        "first_name": "KENNETH",
        "middle_name": "LEE",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2007-04-03",
        "last_updated": "2023-06-15",
        "certification_date": "2023-06-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "AZ",
            "license": "63928",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Anatomic Pathology & Clinical Pathology Physician in San Tan Valley, AZ
• Providers in San Tan Valley, AZ by specialty
• Anatomic Pathology & Clinical Pathology Physician in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 15, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.