Provider Demographics
NPI:1265188072
Name:PERALES, KHEA MEL ESTORNINOS (PTA)
Entity type:Individual
Prefix:
First Name:KHEA MEL
Middle Name:ESTORNINOS
Last Name:PERALES
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 1:4139 70TH ST APT WOODSIDE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-8122
Mailing Address - Country:US
Mailing Address - Phone:719-660-7641
Mailing Address - Fax:
Practice Address - Street 1:4139 70TH ST APT WOODSIDE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-8122
Practice Address - Country:US
Practice Address - Phone:719-660-7641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013089-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant