Provider Demographics
NPI:1689221921
Name:GARNER, DYLAN LEWIS
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:LEWIS
Last Name:GARNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 P.O. BOX
Mailing Address - Street 2:
Mailing Address - City:PERALTA
Mailing Address - State:NM
Mailing Address - Zip Code:87042
Mailing Address - Country:US
Mailing Address - Phone:505-514-5327
Mailing Address - Fax:
Practice Address - Street 1:91 ENTRADA ARAGON RD
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7629
Practice Address - Country:US
Practice Address - Phone:505-514-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program