Individual
AISA MALONZO TAGLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
1660 HOSPITAL DR, RATON, NM 87740-2022
(575) 445-2734
Mailing address
417 PECOS AVE, RATON, NM 87740-4161
(575) 707-8808
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT5029
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
515811125
DRIVER'S LICENSE
NM
Enumeration date
06/27/2019
Last updated
06/27/2019
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