Provider Demographics
NPI:1770909616
Name:CROSS, RONALD (PTA)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:CROSS
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:PO BOX 143
Mailing Address - Street 2:1600 W ROUTE 66
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-0001
Mailing Address - Country:US
Mailing Address - Phone:307-250-0894
Mailing Address - Fax:
Practice Address - Street 1:301 E MIEL DEL LUNA AVE
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-0001
Practice Address - Country:US
Practice Address - Phone:575-461-7230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0791225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant