Healthcare Provider Details

I. General information

NPI: 1154474401
Provider Name (Legal Business Name): SANDRA VAZQUEZ GEUBELLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANDRA LUX PA-C

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 HIGH RESORT BLVD SE
RIO RANCHO NM
87124-5906
US

IV. Provider business mailing address

PO BOX 26666
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-6000
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2006-0008
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: