Healthcare Provider Details

I. General information

NPI: 1306476379
Provider Name (Legal Business Name): ALISSA RENEE HURTADO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2020
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3436 ISLETA BLVD SW
ALBUQUERQUE NM
87105-5837
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-596-2300
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2021-0069
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: