Healthcare Provider Details

I. General information

NPI: 1689780355
Provider Name (Legal Business Name): LOIS MARY PURVIS PA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA ST SUITE D
SANTA FE NM
87505-4073
US

IV. Provider business mailing address

122 CEDAR ST
SANTA FE NM
87501-1638
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-1482
  • Fax: 505-982-0696
Mailing address:
  • Phone: 505-501-4192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2005-0046
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: