Healthcare Provider Details

I. General information

NPI: 1619056553
Provider Name (Legal Business Name): TIMOTHY SEAN DIESEL DOM, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: T SEAN DIESEL DOM, PA-C

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/17/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 PENNSYLVANIA ST NE
ALBUQUERQUE NM
87110-7441
US

IV. Provider business mailing address

8100 CONSTITUTION PL NE
ALBUQUERQUE NM
87110-7643
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2040
  • Fax:
Mailing address:
  • Phone: 505-291-2040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number765
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2009-0010
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: