Healthcare Provider Details

I. General information

NPI: 1114058187
Provider Name (Legal Business Name): DENNIS M. JUARROS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LOS ALAMOS NATIONAL LAB OCCUPATIONAL MEDICINE, MS D421
LOS ALAMOS NM
87545-0001
US

IV. Provider business mailing address

751 COYOTE RIDGE RD
SANTA FE NM
87507-9630
US

V. Phone/Fax

Practice location:
  • Phone: 505-667-7890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number96-PA 20
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: