Provider Demographics
NPI:1073125936
Name:REALISTA, AARON TAN
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:TAN
Last Name:REALISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 YORKWOOD RD S
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-4256
Mailing Address - Country:US
Mailing Address - Phone:251-786-3875
Mailing Address - Fax:
Practice Address - Street 1:21630 MERCHANTS WAY
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-2514
Practice Address - Country:US
Practice Address - Phone:832-230-1518
Practice Address - Fax:281-741-7355
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121049225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist