Healthcare Provider Details

I. General information

NPI: 1760339279
Provider Name (Legal Business Name): GEORGINA PERALTA CRUZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 MED PARK DR
LAS CRUCES NM
88005-3236
US

IV. Provider business mailing address

4573 MESA CORTA DR
LAS CRUCES NM
88011-6040
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-7243
  • Fax:
Mailing address:
  • Phone: 708-465-2032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1676
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: