Provider Demographics
NPI:1124607825
Name:CARRERA, ILDEFONSO (PTA)
Entity type:Individual
Prefix:
First Name:ILDEFONSO
Middle Name:
Last Name:CARRERA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 PVT JUAN GARCIA RD
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:TX
Mailing Address - Zip Code:79927-1323
Mailing Address - Country:US
Mailing Address - Phone:915-479-1473
Mailing Address - Fax:915-440-3148
Practice Address - Street 1:10188 SOCORRO RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79927-2322
Practice Address - Country:US
Practice Address - Phone:915-479-1473
Practice Address - Fax:915-440-3148
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2097261225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1881250215OtherNPPES