Healthcare Provider Details

I. General information

NPI: 1649587726
Provider Name (Legal Business Name): GINA M TORRES BALSAMO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA MARIE TORRES PA-C

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 PASEO DEL PUEBLO SUR STE 125
TAOS NM
87571-7024
US

IV. Provider business mailing address

PO BOX 302
ARROYO SECO NM
87514-0302
US

V. Phone/Fax

Practice location:
  • Phone: 575-751-7430
  • Fax: 575-751-7059
Mailing address:
  • Phone: 575-770-1790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2010-0048
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: