Healthcare Provider Details

I. General information

NPI: 1508161936
Provider Name (Legal Business Name): NEW MEXICO SURGICAL ASSISTING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2011
Last Update Date: 01/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 KACHINA RIDGE DR
SANTA FE NM
87507-5172
US

IV. Provider business mailing address

PO BOX 23974
SANTA FE NM
87502-3974
US

V. Phone/Fax

Practice location:
  • Phone: 505-463-5645
  • Fax: 888-816-6104
Mailing address:
  • Phone: 505-463-5645
  • Fax: 888-816-6104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2005-0035
License Number StateNM

VIII. Authorized Official

Name: VALERIANE M WILSON
Title or Position: PRESIDENT/DIRECTOR
Credential:
Phone: 505-991-5713