Provider Demographics
NPI:1265861280
Name:CARMONA, LUIS GUILLERMO (PTA)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:GUILLERMO
Last Name:CARMONA
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 1:4918 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6725
Mailing Address - Country:US
Mailing Address - Phone:410-203-0424
Mailing Address - Fax:
Practice Address - Street 1:16 FUSTING AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4413
Practice Address - Country:US
Practice Address - Phone:410-747-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA1890225200000X
MDA1890225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant