Provider Demographics
NPI:1922618735
Name:HARE, TALYSSA RENAE (PA)
Entity Type:Individual
Prefix:
First Name:TALYSSA
Middle Name:RENAE
Last Name:HARE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TALYSSA
Other - Middle Name:RENAE
Other - Last Name:VALENCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1600 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2813
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:
Practice Address - Street 1:1600 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2813
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2021-0089363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant