Healthcare Provider Details

I. General information

NPI: 1003132093
Provider Name (Legal Business Name): MITCHELL CONSTANT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 OLD PECOS TRAIL, SUITE H HEALTH FRONT, PC
SANTA FE NM
87505
US

IV. Provider business mailing address

7247 WILD OLIVE AVE NE
ALBUQUERQUE NM
87113-2077
US

V. Phone/Fax

Practice location:
  • Phone: 505-992-0233
  • Fax:
Mailing address:
  • Phone: 505-797-0501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: