Provider Demographics
NPI:1043544091
Name:TELLEZ, DOMINIC (PA)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:TELLEZ
Suffix:
Gender:M
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 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:1600 PHTORPE ROAD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012
Practice Address - Country:US
Practice Address - Phone:575-526-6200
Practice Address - Fax:575-526-2266
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2009-0029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant