Provider Demographics
NPI:1144822677
Name:ORTEGA, LARRY
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10755 E SIMONE AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-9446
Mailing Address - Country:US
Mailing Address - Phone:480-619-3842
Mailing Address - Fax:
Practice Address - Street 1:8607 E PECOS RD STE 116
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-6572
Practice Address - Country:US
Practice Address - Phone:480-500-1446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant