Basic Information
| Provider Information | |||||||||
| NPI: | 1679536585 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEISSINGER | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 111 | ||||||||
| Address2: | |||||||||
| City: | SANDIA PARK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870470111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052810416 | ||||||||
| FaxNumber: | 5052562747 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 SAN PEDRO DR SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871085153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA 81-005 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.