Healthcare Provider Details

I. General information

NPI: 1497728802
Provider Name (Legal Business Name): JENNA LISA HANSCHE PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 CENTRAL AVE SE
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4375
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5885
  • Fax: 505-272-5888
Mailing address:
  • Phone: 505-272-3120
  • Fax: 505-272-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2004-0051
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: