Basic Information
| Provider Information | |||||||||
| NPI: | 1306953062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACOSTA | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | REVELES | ||||||||
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| Credential: | PHYSICAL THERAPIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4849 N MESA ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799125919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9153516600 | ||||||||
| FaxNumber: | 9153516601 | ||||||||
| Practice Location | |||||||||
| Address1: | 11395 JAMES WATT DR STE A6 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799365941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9156297669 | ||||||||
| FaxNumber: | 9156297679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 1061430 | TX | N | Other Service Providers | Specialist | 225100000X | 1061430 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1061430 | 01 | TX | THERAPY LICENSE | OTHER |