Provider Demographics
NPI:1942944699
Name:VASQUEZ, LARISA MAUREEN HART (DPT)
Entity Type:Individual
Prefix:DR
First Name:LARISA
Middle Name:MAUREEN HART
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 OLD US 66
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-7200
Mailing Address - Country:US
Mailing Address - Phone:505-281-8463
Mailing Address - Fax:
Practice Address - Street 1:1851 OLD US 66
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-7200
Practice Address - Country:US
Practice Address - Phone:505-281-8463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5110225100000X
NMNM5110225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist