Provider Demographics
NPI:1487662540
Name:DEGEORGE, ROSALIND MONICA (PA-C)
Entity type:Individual
Prefix:
First Name:ROSALIND
Middle Name:MONICA
Last Name:DEGEORGE
Suffix:
Gender:F
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 1:111 SANDOVAL RD SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7320
Mailing Address - Country:US
Mailing Address - Phone:505-565-4355
Mailing Address - Fax:505-565-4360
Practice Address - Street 1:111 SANDOVAL RD SW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7320
Practice Address - Country:US
Practice Address - Phone:505-565-4355
Practice Address - Fax:505-565-4360
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2005-0054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM202010875OtherPRESBYTERIAN HEALTH PLAN
NMP00340493OtherRAILROAD MEDICARE
NM49050231Medicaid
NM49050231Medicaid
NMQ68848Medicare UPIN
NM349612205Medicare ID - Type Unspecified