Provider Demographics
NPI:1033752357
Name:SPOHN, DANIEL RAY (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAY
Last Name:SPOHN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6205 COCHITI DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4487
Mailing Address - Country:US
Mailing Address - Phone:505-401-2360
Mailing Address - Fax:
Practice Address - Street 1:1630 RIO RANCHO DR SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1587
Practice Address - Country:US
Practice Address - Phone:505-395-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2019-0097363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant