Provider Demographics
NPI:1346242179
Name:LINNELL, LARRY W (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:LINNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 S VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3155
Mailing Address - Country:US
Mailing Address - Phone:575-526-6992
Mailing Address - Fax:575-526-7983
Practice Address - Street 1:1455 S VALLEY DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3155
Practice Address - Country:US
Practice Address - Phone:575-526-6992
Practice Address - Fax:575-526-7983
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027395E207Q00000X
NM99-248207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00075899Medicaid
NM00075899Medicaid
PA0014004550003Medicaid