Healthcare Provider Details

I. General information

NPI: 1891773818
Provider Name (Legal Business Name): PETER R CROTTA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE SUITE 6600
ALBUQUERQUE NM
87106-4917
US

IV. Provider business mailing address

201 CEDAR ST SE SUITE 6600
ALBUQUERQUE NM
87106-4917
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-4300
  • Fax: 505-724-4384
Mailing address:
  • Phone: 505-724-4300
  • Fax: 505-724-4384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number91-165
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number84-PA002
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: