MEDICARE: ROBERT POWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	11476	AZ
2	390200000X	Student in an Organized Health Care Education/Training Program
3	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1043840283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT POWELL

Provider Business Mailing Address
First Line	:	6200 MONTANO PLAZA DR NW APT 2322
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-5784
Country	:	US
Telephone Number	:	208-360-2088
Fax Number	:

Provider Business Practice Location Address
First Line	:	4100 HIGH RESORT BLVD
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-5784
Country	:	US
Telephone Number	:	505-291-2770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2020
Last Update Date	:	04/15/2026

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