Provider Demographics
NPI:1275097941
Name:HERRERA, GUSTAVO JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:
Last Name:HERRERA
Suffix:JR
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 1:10880 EDGEMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-1306
Mailing Address - Country:US
Mailing Address - Phone:915-590-7800
Mailing Address - Fax:
Practice Address - Street 1:10880 EDGEMERE BLVD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-1306
Practice Address - Country:US
Practice Address - Phone:915-590-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2096289225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant