Provider Demographics
NPI:1104851021
Name:LOY, JERALD T (PA)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:T
Last Name:LOY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27829
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125
Mailing Address - Country:US
Mailing Address - Phone:505-262-7026
Mailing Address - Fax:505-727-9276
Practice Address - Street 1:3901 CARLISLE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4503
Practice Address - Country:US
Practice Address - Phone:505-888-8500
Practice Address - Fax:505-888-8503
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0005363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18556019Medicaid
P89846Medicare UPIN
NM18556019Medicaid