Healthcare Provider Details

I. General information

NPI: 1801003868
Provider Name (Legal Business Name): FOTINI YANTSIOS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PHOEBE YANTSIOS

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 S. WILLIAMS ST. BLDG 16
GALLUP NM
87301
US

IV. Provider business mailing address

3009 CINIZA DR
GALLUP NM
87301-4614
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-4383
  • Fax:
Mailing address:
  • Phone: 505-722-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2202
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: