Healthcare Provider Details

I. General information

NPI: 1205490752
Provider Name (Legal Business Name): ALYSON YACONO DPT, PT, CERT. DN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 OLD LAS VEGAS HIGHWAY
SANTA FE NM
87505
US

IV. Provider business mailing address

218 MAYNARD ST APT C
SANTA FE NM
87501-2950
US

V. Phone/Fax

Practice location:
  • Phone: 505-992-4995
  • Fax:
Mailing address:
  • Phone: 856-371-2706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5103
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: