Provider Demographics
NPI:1083784177
Name:PROFESSIONAL PATHOLOGY SERVICES PC
Entity Type:Organization
Organization Name:PROFESSIONAL PATHOLOGY SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PROFESSIONAL PATHOLOGY SE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-769-7257
Mailing Address - Street 1:417 INNSDALE TERRACE
Mailing Address - Street 2:APT B
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:505-762-0824
Mailing Address - Fax:505-769-7243
Practice Address - Street 1:2100 N MLK BLVD
Practice Address - Street 2:PLAINS REGIONAL MEDICAL CENTER
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:505-769-7257
Practice Address - Fax:505-769-7243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8944207ZP0102X
WY2272A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16545Medicaid
A03903Medicare UPIN