Healthcare Provider Details

I. General information

NPI: 1053861385
Provider Name (Legal Business Name): DOMINIC MATTHEW GUERIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 BECKNER RD
SANTA FE NM
87507-3774
US

IV. Provider business mailing address

440 SAINT MICHAELS DR
SANTA FE NM
87505-7602
US

V. Phone/Fax

Practice location:
  • Phone: 505-477-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2016-0075
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: