Healthcare Provider Details

I. General information

NPI: 1427889849
Provider Name (Legal Business Name): GRACE ELIZABETH HOFFMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 HIGHWAY 60 BLDG D
SOCORRO COUNTY NM
87801-3914
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 575-838-4690
  • Fax: 575-838-4689
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2024-0115
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: