Healthcare Provider Details

I. General information

NPI: 1205859543
Provider Name (Legal Business Name): JOSEPHINE M ROBACK PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 RIO RANCHO DR SE
RIO RANCHO NM
87124-1570
US

IV. Provider business mailing address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108-4729
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-8600
  • Fax: 505-896-8618
Mailing address:
  • Phone: 505-262-7960
  • Fax: 505-232-1368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number93-PA11
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: