Provider Demographics
NPI:1083992150
Name:PERALTA, PEDRO (PTA)
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:PERALTA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 ELM ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:NE
Mailing Address - Zip Code:69162-1049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1435 TOLEDO ST
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NE
Practice Address - Zip Code:69162-2166
Practice Address - Country:US
Practice Address - Phone:308-254-4756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-24
Last Update Date:2011-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE841225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant