Provider Demographics
NPI:1518227131
Name:AVERNA, JUSTIN (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:AVERNA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 LOUISIANA BLVD NE # 401
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5103
Mailing Address - Country:US
Mailing Address - Phone:505-260-4300
Mailing Address - Fax:
Practice Address - Street 1:8300 CONSTITUTION AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7613
Practice Address - Country:US
Practice Address - Phone:505-260-4369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-2014-162081P2900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine