Provider Demographics
NPI:1871638403
Name:BALSAMO, BEATRIC E (PA)
Entity type:Individual
Prefix:
First Name:BEATRIC
Middle Name:E
Last Name:BALSAMO
Suffix:
Gender:F
Credentials:PA
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 933
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-0933
Mailing Address - Country:US
Mailing Address - Phone:505-758-0137
Mailing Address - Fax:
Practice Address - Street 1:1399 WEIMER RD STE 200
Practice Address - Street 2:NDCBU BOX 5775
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6349
Practice Address - Country:US
Practice Address - Phone:505-758-2224
Practice Address - Fax:505-758-4903
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM83PA001363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical