=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164434387
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA J SOUTHWARD PAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 07/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 UNIVERISTY BLVD STE 130
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-624-7207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1574
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88202-1574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-624-3470
-----------------------------------------------------
Fax | 575-627-9520
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 95-PA10
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------