Provider Demographics
NPI:1013203694
Name:SELGADO, CANDICE (PA-C)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:SELGADO
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 1:622 W MAPLE ST STE C
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6589
Mailing Address - Country:US
Mailing Address - Phone:505-327-9694
Mailing Address - Fax:505-327-7524
Practice Address - Street 1:622 W MAPLE ST STE C
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6589
Practice Address - Country:US
Practice Address - Phone:505-327-9694
Practice Address - Fax:505-327-7524
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2011-0014363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant