1083784177 NPI number — PROFESSIONAL PATHOLOGY SERVICES PC

Table of content: (NPI 1083784177)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083784177 NPI number — PROFESSIONAL PATHOLOGY SERVICES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PATHOLOGY SERVICES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083784177
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
417 INNSDALE TERRACE
Provider Second Line Business Mailing Address:
APT B
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-762-0824
Provider Business Mailing Address Fax Number:
505-769-7243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 N MLK BLVD
Provider Second Line Business Practice Location Address:
PLAINS REGIONAL MEDICAL CENTER
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-769-7257
Provider Business Practice Location Address Fax Number:
505-769-7243
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT PROFESSIONAL PATHOLOGY SE
Authorized Official Telephone Number:
505-769-7257

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  2272A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 8944 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 16545 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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