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General NPI Number Information
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NPI Number | 1568913911
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Entity Type | Individual
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Provider Name | ISMAEL PEREIRA PA-C
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Gender | Male
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Dates
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Enumeration Date | 10/20/2016
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Last Update Date | 07/28/2022
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Provider Practice Location Address
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Address Line | 4600 MONTGOMERY BLVD NE # B
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City | ALBUQUERQUE
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State | NM
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Zip | 87109
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Country | US
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Telephone | 505-924-5840
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Fax | 505-924-5841
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Provider Business Mailing Address
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Address Line | PO BOX 91224
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City | ALBUQUERQUE
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State | NM
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Zip | 87199-1224
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Country | US
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Telephone | 505-924-5840
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Fax | 505-924-5841
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA20160096
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 202K00000X
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Taxonomy Name | Phlebology Physician
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License Number | PA2016-0096
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License Number State | NM
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