Basic Information
| Provider Information | |||||||||
| NPI: | 1104851021 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOY | ||||||||
| FirstName: | JERALD | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27829 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052627026 | ||||||||
| FaxNumber: | 5057279276 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 CARLISLE BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871074503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058888500 | ||||||||
| FaxNumber: | 5058888503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 02/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA2004-0005 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 18556019 | 05 | NM | MEDICAID |