Healthcare Provider Details

I. General information

NPI: 1912774407
Provider Name (Legal Business Name): PATRICIA ARIELLE CORPUZ MANIO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 UNSER BLVD SE
RIO RANCHO NM
87124-3392
US

IV. Provider business mailing address

PO BOX 26666
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-559-6100
  • Fax: 505-253-1201
Mailing address:
  • Phone: 505-253-1731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2024-0127
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: