Provider Demographics
NPI:1598233439
Name:SOLORIO, VICTOR JESUS (PTA)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:JESUS
Last Name:SOLORIO
Suffix:
Gender:M
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:PO BOX 25346
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-0346
Mailing Address - Country:US
Mailing Address - Phone:682-710-2258
Mailing Address - Fax:
Practice Address - Street 1:165 MCKNIGHT RD N APT 101
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4677
Practice Address - Country:US
Practice Address - Phone:682-710-2258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2140222225200000X
MNA2372225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant