Healthcare Provider Details

I. General information

NPI: 1043879596
Provider Name (Legal Business Name): AMANDA AGUILAR PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2019
Last Update Date: 06/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E COLLEGE AVE STE A
DEVINE TX
78016-2940
US

IV. Provider business mailing address

203 E COLLEGE AVE STE A
DEVINE TX
78016-2940
US

V. Phone/Fax

Practice location:
  • Phone: 830-663-5397
  • Fax: 830-663-5359
Mailing address:
  • Phone:
  • Fax: 830-663-5359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4059280
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: