Healthcare Provider Details

I. General information

NPI: 1497222913
Provider Name (Legal Business Name): ALYSSA DAWN LATHAM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

9100 SAN MATEO BLVD NE APT 2053
ALBUQUERQUE NM
87113-2605
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 859-620-2204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006091RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: