Healthcare Provider Details

I. General information

NPI: 1649140864
Provider Name (Legal Business Name): PHILLIP JEROME GRIEGO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SAINT MICHAELS DR STE 1104
SANTA FE NM
87505-7709
US

IV. Provider business mailing address

PO BOX 384
DIXON NM
87527-0384
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-2562
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2025-0119
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: