Provider Demographics
NPI:1932619137
Name:MODELO, MARCEL MILLADO (PTA)
Entity Type:Individual
Prefix:MR
First Name:MARCEL
Middle Name:MILLADO
Last Name:MODELO
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 1:1692B HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4825
Mailing Address - Country:US
Mailing Address - Phone:505-982-6399
Mailing Address - Fax:505-982-3219
Practice Address - Street 1:1692B HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4825
Practice Address - Country:US
Practice Address - Phone:505-982-6399
Practice Address - Fax:505-982-3219
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0777225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty