Healthcare Provider Details

I. General information

NPI: 1821314857
Provider Name (Legal Business Name): PAVEL JOHN NOCKEL D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-5330
  • Fax: 505-291-2949
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA-2097-17
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: