Basic Information
| Provider Information | |||||||||
| NPI: | 1871703405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAVEZ | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 229 | ||||||||
| Address2: | |||||||||
| City: | PERALTA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870420229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058661731 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 SAN PEDRO SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 95-PA03 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.