Basic Information
| Provider Information | |||||||||
| NPI: | 1699301945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRUJILLO | ||||||||
| FirstName: | CHRIS | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 NEW MEXICO AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877013281 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 GALISTEO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059848313 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2020 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A-345 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3002080327 | 05 | NM | MEDICAID |