Provider Demographics
NPI:1114985660
Name:LAVIGNE, KARI J (PA-C)
Entity Type:Individual
Prefix:
First Name:KARI
Middle Name:J
Last Name:LAVIGNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KARI
Other - Middle Name:J
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:700 LOMAS BLVD NE
Mailing Address - Street 2:3 WOODWARD CENTER
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2568
Mailing Address - Country:US
Mailing Address - Phone:505-242-1711
Mailing Address - Fax:505-242-0189
Practice Address - Street 1:201 CEDAR STREET
Practice Address - Street 2:6600
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-724-4300
Practice Address - Fax:505-724-4384
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2005-0028363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM90808053Medicaid
NM90808053Medicaid