Provider Demographics
NPI:1093706699
Name:DECKER, LAWRENCE ANDREW (PAC)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ANDREW
Last Name:DECKER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 N BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2357
Mailing Address - Country:US
Mailing Address - Phone:505-566-1915
Mailing Address - Fax:505-566-1918
Practice Address - Street 1:3451 N BUTLER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-566-1915
Practice Address - Fax:505-566-1918
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2006-0011261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM66439833Medicaid
AZ875114Medicaid
CO19375336Medicaid
Q26707Medicare UPIN
NM66439833Medicaid
AZ875114Medicaid