Provider Demographics
NPI:1891118741
Name:ARTILLAGA, MARYGRACE (PT)
Entity type:Individual
Prefix:
First Name:MARYGRACE
Middle Name:
Last Name:ARTILLAGA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MARYGRACE
Other - Middle Name:
Other - Last Name:ARTILLAGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2884 N ROADRUNNER PKWY
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-0853
Mailing Address - Country:US
Mailing Address - Phone:512-429-8151
Mailing Address - Fax:
Practice Address - Street 1:2884 N ROADRUNNER PKWY
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-0853
Practice Address - Country:US
Practice Address - Phone:512-429-8151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist