Healthcare Provider Details

I. General information

NPI: 1821020363
Provider Name (Legal Business Name): PINON HILLS EAR NOSE AND THROAT ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST BLDG D-102
FARMINGTON NM
87401-8991
US

IV. Provider business mailing address

2300 E 30TH ST BLDG D-102
FARMINGTON NM
87401-8990
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4429
  • Fax: 505-327-4420
Mailing address:
  • Phone: 505-327-4429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. HAZEL ILENE JACKSON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 505-327-4429