Provider Demographics
NPI:1720590698
Name:MALDONADO, JAIME RICARDO (PTA)
Entity Type:Individual
Prefix:MR
First Name:JAIME
Middle Name:RICARDO
Last Name:MALDONADO
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 1:1000 E AZTEC AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5509
Mailing Address - Country:US
Mailing Address - Phone:505-721-1865
Mailing Address - Fax:500-721-1899
Practice Address - Street 1:204 E LOGAN AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6134
Practice Address - Country:US
Practice Address - Phone:505-728-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-305225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant