Healthcare Provider Details

I. General information

NPI: 1962804930
Provider Name (Legal Business Name): ERIN BONHAM RAYBURN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 BECKNER RD
SANTA FE NM
87507-3774
US

IV. Provider business mailing address

4200 BECKNER RD
SANTA FE NM
87507-3774
US

V. Phone/Fax

Practice location:
  • Phone: 505-477-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2014-0055
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: