Healthcare Provider Details

I. General information

NPI: 1023585163
Provider Name (Legal Business Name): DOMINIC ROMERO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE STE 6600
ALBUQUERQUE NM
87106-5411
US

IV. Provider business mailing address

11055 FORT POINT LN NE
ALBUQUERQUE NM
87123-2675
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-4300
  • Fax:
Mailing address:
  • Phone: 505-231-7136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: