Provider Demographics
NPI:1649587726
Name:TORRES BALSAMO, GINA M (PA-C)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:TORRES BALSAMO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:TORRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 302
Mailing Address - Street 2:
Mailing Address - City:ARROYO SECO
Mailing Address - State:NM
Mailing Address - Zip Code:87514-0302
Mailing Address - Country:US
Mailing Address - Phone:575-770-1790
Mailing Address - Fax:
Practice Address - Street 1:630 PASEO DEL PUEBLO SUR STE 125
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-7024
Practice Address - Country:US
Practice Address - Phone:575-751-7430
Practice Address - Fax:575-751-7059
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2010-0048363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMAAA0219OtherMEDICARE PTAN
NM83383778Medicaid