Healthcare Provider Details

I. General information

NPI: 1902800717
Provider Name (Legal Business Name): RALPH T ZYCH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 JEFFERSON ST NE SUITE 350
ALBUQUERQUE NM
87109-4379
US

IV. Provider business mailing address

6801 JEFFERSON ST NE SUITE 350
ALBUQUERQUE NM
87109-4379
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-1711
  • Fax: 505-242-0291
Mailing address:
  • Phone: 505-242-1711
  • Fax: 505-242-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number81PA014
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: