Provider Demographics
NPI:1063541795
Name:BALSAMO, JOSEPH SALVATORE (PAC)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:SALVATORE
Last Name:BALSAMO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:BX 993
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87521
Mailing Address - Country:US
Mailing Address - Phone:505-758-0137
Mailing Address - Fax:
Practice Address - Street 1:STATE RD 571
Practice Address - Street 2:LAS CLINICAS DEL NONTE BLDG #28
Practice Address - City:EL RITO
Practice Address - State:NM
Practice Address - Zip Code:87530
Practice Address - Country:US
Practice Address - Phone:505-581-4728
Practice Address - Fax:505-581-4789
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNMPA75001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant