Provider Demographics
NPI:1598192924
Name:POSPISAL, JACQUELINE MACY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MACY
Last Name:POSPISAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:5901 HARPER DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3587
Practice Address - Country:US
Practice Address - Phone:505-823-8233
Practice Address - Fax:505-823-8059
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NMPA2016-0061363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical