Healthcare Provider Details

I. General information

NPI: 1194169011
Provider Name (Legal Business Name): MASOUD KHORSAND-SAHBAIE, MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W COUNTRY CLUB RD
ROSWELL NM
88201-5247
US

IV. Provider business mailing address

PO BOX 1574
ROSWELL NM
88202-1574
US

V. Phone/Fax

Practice location:
  • Phone: 575-627-9500
  • Fax: 575-627-9535
Mailing address:
  • Phone: 575-627-9508
  • Fax: 877-749-7764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2011-0207
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2012-0215
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2009-0514
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number89-280
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-01000
License Number StateNM
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-01933
License Number StateNM
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02125
License Number StateNM

VIII. Authorized Official

Name: BRENDA COTTRELL
Title or Position: BUSINESS SYSTEMS/CREDENTIALING MGR
Credential:
Phone: 575-627-9508