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General NPI Number Information
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NPI Number | 1316220478
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Entity Type | Individual
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Provider Name | JESSICA LUCILLA WYACO TSABETSAYE PA
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Gender | Female
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Dates
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Enumeration Date | 09/26/2011
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Last Update Date | 02/05/2015
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Provider Practice Location Address
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Address Line | 5901 HARPER DR NE PMG URGENT CARE
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-3587
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Country | US
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Telephone | 505-823-8233
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Fax | 505-823-8059
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Provider Business Mailing Address
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Address Line | 5712 POTENTILLA CT NW
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City | ALBUQUERQUE
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State | NM
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Zip | 87120-6240
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Country | US
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Telephone | 505-720-0606
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA2011-0034
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License Number State | NM
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