Healthcare Provider Details

I. General information

NPI: 1295191351
Provider Name (Legal Business Name): DUKE CITY SURGICAL ASSISTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 VALLE LINDO RD
PERALTA NM
87042-8230
US

IV. Provider business mailing address

28 VALLE LINDO RD
PERALTA NM
87042-8230
US

V. Phone/Fax

Practice location:
  • Phone: 505-280-5326
  • Fax:
Mailing address:
  • Phone: 505-280-5326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: REGINA K GANTT
Title or Position: PRESIDENT
Credential:
Phone: 505-280-5326