Provider Demographics
NPI:1336191964
Name:DWYER, KAREN (PA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:DWYER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:883 LEAD AVE SE
Mailing Address - Street 2:STE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3644
Mailing Address - Country:US
Mailing Address - Phone:505-247-8820
Mailing Address - Fax:505-246-9421
Practice Address - Street 1:883 LEAD AVE SE
Practice Address - Street 2:STE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3644
Practice Address - Country:US
Practice Address - Phone:505-247-8820
Practice Address - Fax:505-246-9421
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA20030049363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59535318Medicaid
NM59535318Medicaid
NM341421002Medicare PIN