Provider Demographics
NPI:1093141558
Name:LOSTRACCO, MICHELLE (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LOSTRACCO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4091 STATE HIGHWAY 6 S STE B
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-9476
Mailing Address - Country:US
Mailing Address - Phone:979-690-2478
Mailing Address - Fax:
Practice Address - Street 1:4091 STATE HIGHWAY 6 S STE B
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-9476
Practice Address - Country:US
Practice Address - Phone:979-690-2478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4050931225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4050931OtherTEXAS