Healthcare Provider Details

I. General information

NPI: 1679712897
Provider Name (Legal Business Name): GINA C ORTIZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 GALISTEO ST SUITE D
SANTA FE NM
87505-4780
US

IV. Provider business mailing address

1691 GALISTEO ST SUITE D
SANTA FE NM
87505-4780
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-2300
  • Fax: 505-988-1940
Mailing address:
  • Phone: 505-984-2300
  • Fax: 505-988-1940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2008-0049
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: