Provider Demographics
NPI:1902800717
Name:ZYCH, RALPH T (PAC)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:T
Last Name:ZYCH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 JEFFERSON ST NE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4379
Mailing Address - Country:US
Mailing Address - Phone:505-242-1711
Mailing Address - Fax:505-242-0291
Practice Address - Street 1:6801 JEFFERSON ST NE
Practice Address - Street 2:SUITE 350
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4379
Practice Address - Country:US
Practice Address - Phone:505-242-1711
Practice Address - Fax:505-242-0291
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81PA014363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM94471Medicaid
R13202Medicare UPIN
NM344408502 PA81014Medicare PIN