Provider Demographics
NPI:1245828565
Name:DEVORE, JOHN THOMAS (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:DEVORE
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 1:6200 EUBANK BLVD NE APT 1716
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-7321
Mailing Address - Country:US
Mailing Address - Phone:785-331-8873
Mailing Address - Fax:
Practice Address - Street 1:6200 EUBANK BLVD NE APT 1716
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-7321
Practice Address - Country:US
Practice Address - Phone:785-331-8873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-03
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMPA2022-0075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program