Provider Demographics
NPI:1023265063
Name:CARR, MICHAEL (PTA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CARR
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 1:4210 SABANA GRANDE AVE SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1152
Mailing Address - Country:US
Mailing Address - Phone:505-892-6603
Mailing Address - Fax:
Practice Address - Street 1:4210 SABANA GRANDE AVE SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1152
Practice Address - Country:US
Practice Address - Phone:505-892-6603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2008-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE806225100000X
NMA-0640225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
099709OtherMEDICARE GROUP
NE10025112300Medicaid
216812OtherCOVENTRY
39960OtherBCBS
39960OtherBCBS