Healthcare Provider Details

I. General information

NPI: 1114567427
Provider Name (Legal Business Name): KAYLA NOVOA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2559 MEDICAL DR STE 3100
ALAMOGORDO NM
88310-8703
US

IV. Provider business mailing address

2559 MEDICAL DR STE 3100
ALAMOGORDO NM
88310-8703
US

V. Phone/Fax

Practice location:
  • Phone: 575-446-5700
  • Fax: 888-987-7176
Mailing address:
  • Phone: 575-446-5700
  • Fax: 888-987-7176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2022-0073
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: