Provider Demographics
NPI:1265610695
Name:ALHAMODY, MAZEN I (SA-C)
Entity type:Individual
Prefix:
First Name:MAZEN
Middle Name:I
Last Name:ALHAMODY
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W BOUTZ RD
Mailing Address - Street 2:BLDG # 1
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3262
Mailing Address - Country:US
Mailing Address - Phone:575-532-7000
Mailing Address - Fax:
Practice Address - Street 1:2311 N MESA ST
Practice Address - Street 2:STE C
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3575
Practice Address - Country:US
Practice Address - Phone:915-545-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07-339363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical