Healthcare Provider Details

I. General information

NPI: 1881214294
Provider Name (Legal Business Name): JANG GARCIA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2020
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 PASEO DEL NORTE BLVD NE
ALBEQUERQUE NM
87113-1718
US

IV. Provider business mailing address

PO BOX 26666
ALBEQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-596-2100
  • Fax: 505-596-2180
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2021-0040
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA7636
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: