Provider Demographics
NPI:1720071186
Name:NORTH, DOUGLAS A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:A
Last Name:NORTH
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:PO BOX 158
Mailing Address - Street 2:538 N. PASEO DE ONATE
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:15136 ST. RD. 75
Practice Address - Street 2:
Practice Address - City:PENASCO
Practice Address - State:NM
Practice Address - Zip Code:87553-0238
Practice Address - Country:US
Practice Address - Phone:575-587-2205
Practice Address - Fax:575-587-1944
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-PA27363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81958757Medicaid
NMNM400307OtherMEDICARE PTAN