Provider Demographics
NPI:1528230117
Name:WYLIE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WYLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-1754
Mailing Address - Fax:
Practice Address - Street 1:1101 MEDICAL ARTS AVE NE # 4
Practice Address - Street 2:BUILDING 4, SUITE A, UNM SENIOR HEALTH
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2706
Practice Address - Country:US
Practice Address - Phone:505-272-1754
Practice Address - Fax:505-325-4594
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2007-0038363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical