Healthcare Provider Details

I. General information

NPI: 1679536585
Provider Name (Legal Business Name): ALAN EDWARD DEISSINGER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

PO BOX 111
SANDIA PARK NM
87047-0111
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-281-0416
  • Fax: 505-256-2747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 81-005
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: