Provider Demographics
NPI:1831679984
Name:SALAZAR, JESSE (PTA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:SALAZAR
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 1:315 W 3RD PL
Mailing Address - Street 2:
Mailing Address - City:ELOY
Mailing Address - State:AZ
Mailing Address - Zip Code:85131-2312
Mailing Address - Country:US
Mailing Address - Phone:520-582-5396
Mailing Address - Fax:
Practice Address - Street 1:315 W 3RD PL
Practice Address - Street 2:
Practice Address - City:ELOY
Practice Address - State:AZ
Practice Address - Zip Code:85131-2312
Practice Address - Country:US
Practice Address - Phone:520-582-5396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
AZ11854A2081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11854AMedicaid