Provider Demographics
NPI:1558734665
Name:CORTAZZO, JOHNATHON (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:
Last Name:CORTAZZO
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 LOS PRESIDENTES AVE
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78046-6044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 LOS PRESIDENTES AVE
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78046-6044
Practice Address - Country:US
Practice Address - Phone:956-473-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXAT66682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program