Provider Demographics
NPI:1598845745
Name:MAMARIL, JOHANNA PAZ (RPT)
Entity Type:Individual
Prefix:MISS
First Name:JOHANNA
Middle Name:PAZ
Last Name:MAMARIL
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2301 GOLF COURSE RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-4971
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:760-321-7277
Practice Address - Street 1:2301 GOLF COURSE RD SE STE 245
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4971
Practice Address - Country:US
Practice Address - Phone:978-618-7500
Practice Address - Fax:760-321-7277
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29464225100000X
NM5970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT294640Medicare PIN