Healthcare Provider Details

I. General information

NPI: 1831596998
Provider Name (Legal Business Name): REGINA PERKINS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 E HOLLY ST SUITE B
DEMING NM
88030-5245
US

IV. Provider business mailing address

721 E HOLLY ST SUITE B
DEMING NM
88030-5245
US

V. Phone/Fax

Practice location:
  • Phone: 575-546-6010
  • Fax: 575-546-4099
Mailing address:
  • Phone: 575-546-6010
  • Fax: 575-546-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2014-0078
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: