Healthcare Provider Details

I. General information

NPI: 1215245287
Provider Name (Legal Business Name): JAMES MARC BEVERLY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARC BEVERLY PA-C

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 IMPERATA ST NE #2422
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

6101 IMPERATA ST NE #2422
ALBUQUERQUE NM
87111
US

V. Phone/Fax

Practice location:
  • Phone: 505-264-8364
  • Fax: 888-823-2280
Mailing address:
  • Phone: 505-264-8364
  • Fax: 888-823-2280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2001-PA16
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: