Healthcare Provider Details

I. General information

NPI: 1699782102
Provider Name (Legal Business Name): PATRICK M. DALESSIO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 EAST NIZHONI BLVD.
GALLUP NM
87301-1337
US

IV. Provider business mailing address

P.O. BOX 1337
GALLUP NM
87305-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-726-8671
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-726-8671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004407
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004407
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10004407
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: