Individual
MR. IMTIAZ A MALIK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2400 UNSER BLVD SE, RIO RANCHO, NM 87124-4740
(505) 559-6100
(505) 559-6101
Mailing address
PO BOX 26666, PHS PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA2002-0028
NM
363AM0700X
Medical Physician Assistant
PA2002-0028
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
32486006
—
NM
Enumeration date
11/11/2005
Last updated
03/17/2018
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