Healthcare Provider Details

I. General information

NPI: 1083288930
Provider Name (Legal Business Name): JASON THOMAS MCKINNEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2021
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 HARPER DR NE
ALBUQUERQUE NM
87109-3587
US

IV. Provider business mailing address

7557 UNION ST NE
ALBUQUERQUE NM
87109-4948
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8888
  • Fax:
Mailing address:
  • Phone: 505-463-5329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0072
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: