Basic Information
| Provider Information | |||||||||
| NPI: | 1043840283 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | ROBERT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6200 MONTANO PLAZA DR NW APT 2322 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871205784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083602088 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4100 HIGH RESORT BLVD | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871245784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052912770 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2020 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.