Provider Demographics
NPI:1891773818
Name:CROTTA, PETER R (PA-C)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:R
Last Name:CROTTA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CEDAR ST SE
Mailing Address - Street 2:SUITE 6600
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4917
Mailing Address - Country:US
Mailing Address - Phone:505-724-4300
Mailing Address - Fax:505-724-4384
Practice Address - Street 1:201 CEDAR ST SE
Practice Address - Street 2:SUITE 6600
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4917
Practice Address - Country:US
Practice Address - Phone:505-724-4300
Practice Address - Fax:505-724-4384
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-165363A00000X
NM84-PA002363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00093328Medicaid
NM00093328Medicaid
349300902Medicare ID - Type Unspecified