Provider Demographics
NPI:1699135111
Name:CHAVEZ, DANIEL (PTA)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:CHAVEZ
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 1:515 W CASTILLO AVE
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-3525
Mailing Address - Country:US
Mailing Address - Phone:505-715-8287
Mailing Address - Fax:
Practice Address - Street 1:9150 MCMAHON BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5201
Practice Address - Country:US
Practice Address - Phone:505-898-5122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1229225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant