Provider Demographics
NPI:1538624226
Name:CEBALLOS, ISAAC JOHN (PTA)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:JOHN
Last Name:CEBALLOS
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 1:444 EXECUTIVE CENTER BLVD STE 148
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1096
Mailing Address - Country:US
Mailing Address - Phone:915-600-2796
Mailing Address - Fax:
Practice Address - Street 1:444 EXECUTIVE CENTER BLVD STE 148
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-1096
Practice Address - Country:US
Practice Address - Phone:915-600-2796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2097577225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant