Provider Demographics
NPI:1699336826
Name:TAGLE, AISA MALONZO (PT)
Entity type:Individual
Prefix:
First Name:AISA
Middle Name:MALONZO
Last Name:TAGLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 PECOS AVE
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-4161
Mailing Address - Country:US
Mailing Address - Phone:575-707-8808
Mailing Address - Fax:
Practice Address - Street 1:1660 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2022
Practice Address - Country:US
Practice Address - Phone:575-445-2734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5029225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM515811125OtherDRIVER'S LICENSE