Healthcare Provider Details

I. General information

NPI: 1497473391
Provider Name (Legal Business Name): THE PAGOSA MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E 12TH ST
DURANGO CO
81301-5206
US

IV. Provider business mailing address

27B TALISMAN DR UNIT 3
PAGOSA SPRINGS CO
81147-7914
US

V. Phone/Fax

Practice location:
  • Phone: 970-372-0456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: RHONDA L ASH
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 970-372-0456