Provider Demographics
NPI:1891036661
Name:MAESTRE, RANDY P (PTA)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:P
Last Name:MAESTRE
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 962500
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79996-2500
Mailing Address - Country:US
Mailing Address - Phone:915-849-6602
Mailing Address - Fax:915-849-6603
Practice Address - Street 1:3022 TRAWOOD DR
Practice Address - Street 2:STE. B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4329
Practice Address - Country:US
Practice Address - Phone:915-849-6602
Practice Address - Fax:915-849-6603
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2047876225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant