Provider Demographics
NPI:1578011094
Name:LALLY, BARTHOLOMEW J (PA-C)
Entity Type:Individual
Prefix:
First Name:BARTHOLOMEW
Middle Name:J
Last Name:LALLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:BART
Other - Middle Name:
Other - Last Name:LALLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:933 SAN MATEO NE SUITE 500 #174
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108
Mailing Address - Country:US
Mailing Address - Phone:505-204-5150
Mailing Address - Fax:505-494-1056
Practice Address - Street 1:933 SAN MATEO BLVD NE STE 500
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1862
Practice Address - Country:US
Practice Address - Phone:505-204-5150
Practice Address - Fax:505-494-1056
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2016-0077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMI20161110001090Medicare Oscar/Certification