Provider Demographics
NPI:1205297371
Name:MORALES, PETRA
Entity type:Individual
Prefix:MRS
First Name:PETRA
Middle Name:
Last Name:MORALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 JERRY LEWIS
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936
Mailing Address - Country:US
Mailing Address - Phone:915-329-2372
Mailing Address - Fax:
Practice Address - Street 1:11501 JERRY LEWIS
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936
Practice Address - Country:US
Practice Address - Phone:915-329-2372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF500229640Medicare UPIN