Provider Demographics
NPI:1891274874
Name:DE LA O, JOSUE (PTA)
Entity Type:Individual
Prefix:
First Name:JOSUE
Middle Name:
Last Name:DE LA O
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 1:2904 S JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-1870
Mailing Address - Country:US
Mailing Address - Phone:956-631-8646
Mailing Address - Fax:
Practice Address - Street 1:2904 S JACKSON RD
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1870
Practice Address - Country:US
Practice Address - Phone:956-631-8646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2056048225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty