Healthcare Provider Details

I. General information

NPI: 1922581776
Provider Name (Legal Business Name): ADAM HENRY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MADEIRA DR SE
ALBUQUERQUE NM
87108-2963
US

IV. Provider business mailing address

215 LEAD AVE SW APT 1308
ALBUQUERQUE NM
87102-4080
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-1538
  • Fax:
Mailing address:
  • Phone: 505-274-6611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0108
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: