Provider Demographics
NPI:1245755230
Name:SEDILLO, JASON CARLOS
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:CARLOS
Last Name:SEDILLO
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 1:535 HWY 314 SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9600
Mailing Address - Country:US
Mailing Address - Phone:505-866-0055
Mailing Address - Fax:
Practice Address - Street 1:535 HWY 314 SW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-9600
Practice Address - Country:US
Practice Address - Phone:505-866-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5121225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist