Facts
- Status
- A
- Credential
- PA-C
- Type
- Individual
- Enumeration date
- 2010-06-07
- Last updated
- 2019-06-25
Licenses
- License TX
- PA06228
- License CO
- PA.0005385
- License NM
- PA2018-0040
Location
- Practice location
- 604 S RIO GRANDE AVE
- City
- AZTEC NM
- Postal code
- 874102260
- Phone
- 505-334-2664
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
Search this city from the state hub for other records in the public registry.
Removal request
Public data from NPPES and CMS. Not a credentialing determination.