Provider Demographics
NPI:1205859543
Name:ROBACK, JOSEPHINE M (PAC)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:M
Last Name:ROBACK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 GIBSON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4729
Mailing Address - Country:US
Mailing Address - Phone:505-262-7960
Mailing Address - Fax:505-232-1368
Practice Address - Street 1:1721 RIO RANCHO DR SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1570
Practice Address - Country:US
Practice Address - Phone:505-896-8600
Practice Address - Fax:505-896-8618
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM93-PA11363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R14611Medicare UPIN
NM98566Medicaid
NMPA009311Medicare ID - Type Unspecified