Healthcare Provider Details

I. General information

NPI: 1407504731
Provider Name (Legal Business Name): ALEXIS ADRIAN PORTILLO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11601 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2660
US

IV. Provider business mailing address

1009 FLEMING RD
BLOOMFIELD NM
87413-6544
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-7896
  • Fax:
Mailing address:
  • Phone: 505-609-7896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2022-0133
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0133
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: