Provider Demographics
NPI:1992198220
Name:HUANTE BAJO, SERGIO
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:HUANTE BAJO
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 1:6862 S DENNIS DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-5431
Mailing Address - Country:US
Mailing Address - Phone:928-246-3015
Mailing Address - Fax:
Practice Address - Street 1:6862 S DENNIS DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-5431
Practice Address - Country:US
Practice Address - Phone:928-246-3015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11430A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant