Healthcare Provider Details

I. General information

NPI: 1528230117
Provider Name (Legal Business Name): LAURA WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MEDICAL ARTS AVE NE # 4 BUILDING 4, SUITE A, UNM SENIOR HEALTH
ALBUQUERQUE NM
87102-2706
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-1754
  • Fax: 505-325-4594
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2007-0038
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: