Basic Information
| Provider Information | |||||||||
| NPI: | 1982142089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HORTALEZA | ||||||||
| FirstName: | NIGEL PAUL | ||||||||
| MiddleName: | FILLER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4704 GLENLEA DR | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718541728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325083071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4100 MOORES LN | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755035102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038312969 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2017 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4257 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1284298 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.