Healthcare Provider Details

I. General information

NPI: 1194367862
Provider Name (Legal Business Name): RODRIGO PEREZ-RESENDIZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 DON PASQUAL RD NW
LOS LUNAS NM
87031-8841
US

IV. Provider business mailing address

127 SANDOVAL RD SW
LOS LUNAS NM
87031-7320
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-4618
  • Fax: 505-224-8727
Mailing address:
  • Phone: 505-865-3373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1194827535
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2019-0088
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: