Healthcare Provider Details

I. General information

NPI: 1710971015
Provider Name (Legal Business Name): PAUL A VAKSELIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 02/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 HILLRISE DR
LAS CRUCES NM
88011-4701
US

IV. Provider business mailing address

PO BOX 1560
LAS CRUCES NM
88004-1560
US

V. Phone/Fax

Practice location:
  • Phone: 505-522-5888
  • Fax: 505-521-1876
Mailing address:
  • Phone: 505-647-8366
  • Fax: 505-647-8387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2000120
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: