Healthcare Provider Details

I. General information

NPI: 1225457260
Provider Name (Legal Business Name): FOROUZ JOWKAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 ASPEN DR # 100B
SANTA FE NM
87505-5459
US

IV. Provider business mailing address

1925 ASPEN DR # 100B
SANTA FE NM
87505-5459
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-9172
  • Fax: 505-438-1814
Mailing address:
  • Phone: 505-424-9172
  • Fax: 505-438-1814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2008-0051
License Number StateNM

VIII. Authorized Official

Name: FOROUZ JOWKAR
Title or Position: CEO MEDICAL DIRECTOR
Credential: PA
Phone: 505-424-9172