Healthcare Provider Details

I. General information

NPI: 1265524177
Provider Name (Legal Business Name): KEVIN JAY REGAN PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON SE LOVELACE MEDICAL CENTER
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

PO BOX 27829 LOVELACE MEDICAL GROUP
ALBUQUERQUE NM
87125
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7000
  • Fax:
Mailing address:
  • Phone: 505-262-7026
  • Fax: 505-727-9276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA20030004
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: