Provider Demographics
NPI:1538317771
Name:BALSAMO, ABRAHAM THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ABRAHAM
Middle Name:THOMAS
Last Name:BALSAMO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:630 PASEO DEL PUEBLO SUR STE 125
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-7024
Mailing Address - Country:US
Mailing Address - Phone:575-751-7430
Mailing Address - Fax:575-751-7059
Practice Address - Street 1:630 PASEO DEL PUEBLO SUR
Practice Address - Street 2:SUITE 150
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6070
Practice Address - Country:US
Practice Address - Phone:575-758-3005
Practice Address - Fax:575-758-7010
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2008-0042363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM320956YS0ZMedicare PIN