1316685027 NPI number — ANGELICA MARIE MALDONADO PT, DPT

Table of content: ANGELICA MARIE MALDONADO PT, DPT (NPI 1316685027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316685027 NPI number — ANGELICA MARIE MALDONADO PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALDONADO
Provider First Name:
ANGELICA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316685027
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 HIGUERA ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93401-6135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-788-0805
Provider Business Mailing Address Fax Number:
805-788-0845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 S LA CANADA DR STE 35
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85614-2663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-365-0750
Provider Business Practice Location Address Fax Number:
520-441-1465
Provider Enumeration Date:
05/23/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  LPT32355 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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