Provider Demographics
NPI:1144815663
Name:KRISKO, THOMAS JAMES (PTA)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JAMES
Last Name:KRISKO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 ROSETTA CT
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-0773
Mailing Address - Country:US
Mailing Address - Phone:619-592-0142
Mailing Address - Fax:
Practice Address - Street 1:79440 CORPORATE CENTER DR STE 112
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7243
Practice Address - Country:US
Practice Address - Phone:760-771-9054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51036225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant