Healthcare Provider Details

I. General information

NPI: 1306911243
Provider Name (Legal Business Name): LARRY EVERETT HAMNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8324 CONSTITUTION PL NE
ALBUQUERQUE NM
87110-7651
US

IV. Provider business mailing address

8324 CONSTITUTION PL NE
ALBUQUERQUE NM
87110-7651
US

V. Phone/Fax

Practice location:
  • Phone: 505-293-8000
  • Fax: 505-293-8004
Mailing address:
  • Phone: 505-293-8000
  • Fax: 505-293-8004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-04
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: