Healthcare Provider Details

I. General information

NPI: 1790282242
Provider Name (Legal Business Name): DANE THOMAS GARDEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 505-272-2711
  • Fax:
Mailing address:
  • Phone: 505-272-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2018-0023
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13422
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: