Healthcare Provider Details

I. General information

NPI: 1275032187
Provider Name (Legal Business Name): ROSEMARY C RODRIGUEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 TIJERAS AVE NE STE 22
ALBUQUERQUE NM
87106-4749
US

IV. Provider business mailing address

1020 TIJERAS AVE NE STE 22
ALBUQUERQUE NM
87106-4749
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-1670
  • Fax: 505-727-9590
Mailing address:
  • Phone: 505-727-1670
  • Fax: 505-727-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2017-0070
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: