Provider Demographics
NPI:1831628841
Name:DO, LOC VAN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:LOC
Middle Name:VAN
Last Name:DO
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 COORS BYP NW APT 313
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4142
Mailing Address - Country:US
Mailing Address - Phone:408-205-6681
Mailing Address - Fax:
Practice Address - Street 1:505 ELM ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2500
Practice Address - Country:US
Practice Address - Phone:505-727-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant