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General NPI Number Information
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NPI Number | 1508161936
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Entity Type | Organization
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Legal Business Name | NEW MEXICO SURGICAL ASSISTING, INC
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Dates
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Enumeration Date | 01/15/2011
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Last Update Date | 01/15/2011
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Provider Practice Location Address
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Address Line | 1505 KACHINA RIDGE DR
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City | SANTA FE
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State | NM
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Zip | 87507-5172
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Country | US
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Telephone | 505-463-5645
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Fax | 888-816-6104
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Provider Business Mailing Address
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Address Line | PO BOX 23974
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City | SANTA FE
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State | NM
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Zip | 87502-3974
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Country | US
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Telephone | 505-463-5645
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Fax | 888-816-6104
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Authorized Official
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Title or Position | PRESIDENT/DIRECTOR
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Name | VALERIANE M WILSON
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Credential |
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Telephone | 505-991-5713
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA2005-0035
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License Number State | NM
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