Provider Demographics
NPI:1467011767
Name:RUTAQUIO, PAMELA (PT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:RUTAQUIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13907 MONTFORT DR APT 1325
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-7354
Mailing Address - Country:US
Mailing Address - Phone:615-618-6606
Mailing Address - Fax:
Practice Address - Street 1:6301 GASTON AVE STE 750
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-6339
Practice Address - Country:US
Practice Address - Phone:214-295-5374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12058812251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics