Healthcare Provider Details

I. General information

NPI: 1518227131
Provider Name (Legal Business Name): JUSTIN AVERNA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

1720 LOUISIANA BLVD NE # 401
ALBUQUERQUE NM
87110-5103
US

V. Phone/Fax

Practice location:
  • Phone: 505-260-4369
  • Fax:
Mailing address:
  • Phone: 505-260-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA-2014-16
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: