Provider Demographics
NPI:1679536585
Name:DEISSINGER, ALAN EDWARD (PA)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:EDWARD
Last Name:DEISSINGER
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 111
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-0111
Mailing Address - Country:US
Mailing Address - Phone:505-281-0416
Mailing Address - Fax:505-256-2747
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA 81-005363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical