Provider Demographics
NPI:1871220327
Name:DAVALOS, PRISMA (PA-C)
Entity type:Individual
Prefix:
First Name:PRISMA
Middle Name:
Last Name:DAVALOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0299
Mailing Address - Country:US
Mailing Address - Phone:575-356-6652
Mailing Address - Fax:575-359-6827
Practice Address - Street 1:42121 US HWY 70
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130
Practice Address - Country:US
Practice Address - Phone:575-356-6652
Practice Address - Fax:575-359-6827
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical