Provider Demographics
NPI:1265292130
Name:VELAZCO, MYRA KARINA (PTA)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:KARINA
Last Name:VELAZCO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 21ST ST APT B
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2816
Mailing Address - Country:US
Mailing Address - Phone:619-804-6327
Mailing Address - Fax:
Practice Address - Street 1:885 CANARIOS CT STE 110
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7877
Practice Address - Country:US
Practice Address - Phone:619-656-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50987225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant