Provider Demographics
NPI:1801836523
Name:ABERNETHY, HOLLY (MD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:
Last Name:ABERNETHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 E 30TH ST
Mailing Address - Street 2:BLDG C-2
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8990
Mailing Address - Country:US
Mailing Address - Phone:505-324-1000
Mailing Address - Fax:505-324-1199
Practice Address - Street 1:2300 E 30TH ST
Practice Address - Street 2:BLDG C-2
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-324-1000
Practice Address - Fax:505-324-1199
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2006-0481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80488277Medicaid
NMP00796812OtherRAILROAD RETIREMENT PTAN
NM80488277Medicaid
VA009535C61Medicare ID - Type Unspecified