Healthcare Provider Details

I. General information

NPI: 1720071186
Provider Name (Legal Business Name): DOUGLAS A. NORTH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15136 ST. RD. 75
PENASCO NM
87553-0238
US

IV. Provider business mailing address

PO BOX 158 538 N. PASEO DE ONATE
ESPANOLA NM
87532-0158
US

V. Phone/Fax

Practice location:
  • Phone: 575-587-2205
  • Fax: 575-587-1944
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-753-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2001-PA27
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: