Provider Demographics
NPI:1326539339
Name:MURRIETTA, ELISA D
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:D
Last Name:MURRIETTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 N CAMINO SECO APT 2114
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-2976
Mailing Address - Country:US
Mailing Address - Phone:520-440-9174
Mailing Address - Fax:
Practice Address - Street 1:2040 N WILMOT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3039
Practice Address - Country:US
Practice Address - Phone:520-300-6115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8367A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant