Provider Demographics
NPI:1053422956
Name:ALCON, KATHLEEN A (PT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:ALCON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1398 WEIMER RD
Mailing Address - Street 2:STE 203
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:575-737-0304
Mailing Address - Fax:575-737-0383
Practice Address - Street 1:1398 WEIMER RD
Practice Address - Street 2:STE 203
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-737-0304
Practice Address - Fax:575-737-0383
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2858225100000X
NM453208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM43383386Medicaid
NM43383386Medicaid