Healthcare Provider Details

I. General information

NPI: 1316220478
Provider Name (Legal Business Name): JESSICA LUCILLA WYACO TSABETSAYE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 HARPER DR NE PMG URGENT CARE
ALBUQUERQUE NM
87109-3587
US

IV. Provider business mailing address

5712 POTENTILLA CT NW
ALBUQUERQUE NM
87120-6240
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8233
  • Fax: 505-823-8059
Mailing address:
  • Phone: 505-720-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2011-0034
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: