Provider Demographics
NPI:1073591095
Name:VANZELST, JACOBUS G (PT)
Entity Type:Individual
Prefix:
First Name:JACOBUS
Middle Name:G
Last Name:VANZELST
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 SARA WAY SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-0999
Mailing Address - Country:US
Mailing Address - Phone:505-377-3841
Mailing Address - Fax:505-891-7811
Practice Address - Street 1:1361 SARA WAY SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-0999
Practice Address - Country:US
Practice Address - Phone:505-377-3841
Practice Address - Fax:505-891-7811
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1012225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM48677876Medicaid
343505600Medicare ID - Type Unspecified