Provider Demographics
NPI:1679345789
Name:LETCHER, MIRANDA ALICE (PTA)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ALICE
Last Name:LETCHER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 CABEZON BLVD SE STE 102
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1513
Mailing Address - Country:US
Mailing Address - Phone:505-994-2599
Mailing Address - Fax:
Practice Address - Street 1:2401 CABEZON BLVD SE STE 102
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1513
Practice Address - Country:US
Practice Address - Phone:505-994-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPTA-2023-2329225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant