Healthcare Provider Details

I. General information

NPI: 1306942792
Provider Name (Legal Business Name): GARY JOHN TEARE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3451 N BUTLER AVE
FARMINGTON NM
87401
US

IV. Provider business mailing address

3451 N BUTLER AVE
FARMINGTON NM
87401-2357
US

V. Phone/Fax

Practice location:
  • Phone: 505-566-1915
  • Fax: 505-566-1918
Mailing address:
  • Phone: 505-566-1915
  • Fax: 505-566-1918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number98-PA13
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: