Provider Demographics
NPI:1689158479
Name:AGUSTIN, VICTORIA TIAMZON
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:TIAMZON
Last Name:AGUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 LEAD AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4434
Mailing Address - Country:US
Mailing Address - Phone:505-903-8469
Mailing Address - Fax:
Practice Address - Street 1:4401 MASTHEAD ST NE STE 105
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4682
Practice Address - Country:US
Practice Address - Phone:505-345-3754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT4938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist