Healthcare Provider Details

I. General information

NPI: 1437989738
Provider Name (Legal Business Name): RAPHAEL DIAZ-MALPICA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 E LOHMAN AVE
LAS CRUCES NM
88011-8255
US

IV. Provider business mailing address

801 LUNA DR UNIT 1
CHAPARRAL NM
88081-7691
US

V. Phone/Fax

Practice location:
  • Phone: 575-556-7600
  • Fax:
Mailing address:
  • Phone: 915-206-8322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number16-395
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: