Healthcare Provider Details

I. General information

NPI: 1720928880
Provider Name (Legal Business Name): ITXCHEL YESENIA DE LA ROSA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 COMMONS AVE NE
ALBUQUERQUE NM
87109-5831
US

IV. Provider business mailing address

PO BOX 33286
SANTA FE NM
87594-3286
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-1239
  • Fax: 505-808-7278
Mailing address:
  • Phone: 505-424-1239
  • Fax: 505-808-7278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2025-0027
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: