Provider Demographics
NPI:1942288147
Name:BOYER, RANDY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:BOYER
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 1:4401 E LOHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8267
Mailing Address - Country:US
Mailing Address - Phone:575-532-9077
Mailing Address - Fax:575-532-9221
Practice Address - Street 1:4401 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8267
Practice Address - Country:US
Practice Address - Phone:575-532-9077
Practice Address - Fax:575-532-9221
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94-PA06363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00099985Medicaid
NM00099985Medicaid