Provider Demographics
NPI:1699331991
Name:PASTORFIDE, LEO ANTIPATIA III (DPT)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:ANTIPATIA
Last Name:PASTORFIDE
Suffix:III
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4722
Mailing Address - Country:US
Mailing Address - Phone:505-347-8655
Mailing Address - Fax:575-627-5934
Practice Address - Street 1:227 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4722
Practice Address - Country:US
Practice Address - Phone:505-347-8655
Practice Address - Fax:575-627-5934
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist