Healthcare Provider Details

I. General information

NPI: 1043676273
Provider Name (Legal Business Name): KYLE MAESTAS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 JEFFERSON ST NE STE 750
ALBUQUERQUE NM
87109-2132
US

IV. Provider business mailing address

500 WALTER ST NE
ALBUQUERQUE NM
87102-2534
US

V. Phone/Fax

Practice location:
  • Phone: 505-418-6636
  • Fax:
Mailing address:
  • Phone: 505-727-4430
  • Fax: 505-727-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: