Provider Demographics
NPI:1578135521
Name:VINING, ALEXANDER THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:THOMAS
Last Name:VINING
Suffix:
Gender:M
Credentials:PA-C
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 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:1010 SPRUCE ST
Practice Address - Street 2:ENERGENCY MEDICINE - ESPANOLA
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2746
Practice Address - Country:US
Practice Address - Phone:505-753-7111
Practice Address - Fax:505-367-0263
Is Sole Proprietor?:No
Enumeration Date:2021-07-10
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2021-0060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant