Healthcare Provider Details

I. General information

NPI: 1255703492
Provider Name (Legal Business Name): ELISHA SALCIDO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10511 GOLF COURSE RD NW SUITE 103
ALBUQUERQUE NM
87114-5916
US

IV. Provider business mailing address

PO BOX 26028 SUITE 103
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7281
  • Fax:
Mailing address:
  • Phone: 505-262-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2015-0080
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: