Provider Demographics
NPI:1417366303
Name:HERRADOR, MAURICIO A
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:A
Last Name:HERRADOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 GRANDVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3015
Mailing Address - Country:US
Mailing Address - Phone:509-431-8035
Mailing Address - Fax:
Practice Address - Street 1:1401 EMERSON RD
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-8437
Practice Address - Country:US
Practice Address - Phone:509-431-8035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60044952225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant