Provider Demographics
NPI:1639395221
Name:RODRIGUEZ, BARNIE P (PA)
Entity Type:Individual
Prefix:MR
First Name:BARNIE
Middle Name:P
Last Name:RODRIGUEZ
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 1974
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1974
Mailing Address - Country:US
Mailing Address - Phone:575-623-1303
Mailing Address - Fax:575-622-1903
Practice Address - Street 1:1700 N UNION AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3267
Practice Address - Country:US
Practice Address - Phone:575-623-1303
Practice Address - Fax:575-623-1903
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM93-PA21363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMS45152Medicare UPIN