Healthcare Provider Details

I. General information

NPI: 1730309758
Provider Name (Legal Business Name): WALTER DAVID SELVAGE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 S SAINT FRANCIS DR
SANTA FE NM
87505-4173
US

IV. Provider business mailing address

2720 CALLE CEDRO
SANTA FE NM
87505-5297
US

V. Phone/Fax

Practice location:
  • Phone: 505-827-0006
  • Fax:
Mailing address:
  • Phone: 505-660-4282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number94-PA05
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: