Provider Demographics
NPI:1972069060
Name:AVITIA, ADRIAN ELOY
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:ELOY
Last Name:AVITIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ANNA MARIA PL SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-6480
Mailing Address - Country:US
Mailing Address - Phone:505-977-4948
Mailing Address - Fax:
Practice Address - Street 1:205 ANNA MARIA PL SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-6480
Practice Address - Country:US
Practice Address - Phone:505-977-4948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPTA1625225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant