Healthcare Provider Details

I. General information

NPI: 1497048011
Provider Name (Legal Business Name): JONATHAN BRENT HANCOCK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST STE 101
FARMINGTON NM
87401-8990
US

IV. Provider business mailing address

2300 E 30TH ST STE 101
FARMINGTON NM
87401-8990
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-1400
  • Fax: 505-564-3202
Mailing address:
  • Phone: 505-327-1400
  • Fax: 505-564-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA-1965-16
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberA-1965-16
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberA-1965-16
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: