Provider Demographics
NPI:1437648441
Name:WILLIS, TALOA (PTA)
Entity Type:Individual
Prefix:
First Name:TALOA
Middle Name:
Last Name:WILLIS
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 1:4210 SABANA GRANDE AVE SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1152
Mailing Address - Country:US
Mailing Address - Phone:505-892-6603
Mailing Address - Fax:505-891-8774
Practice Address - Street 1:4210 SABANA GRANDE AVE SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1152
Practice Address - Country:US
Practice Address - Phone:505-892-6603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1450225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty