Basic Information
| Provider Information | |||||||||
| NPI: | 1477675015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YERXA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 DE MOSS ST | ||||||||
| Address2: | |||||||||
| City: | LORDSBURG | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880452618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755428384 | ||||||||
| FaxNumber: | 5755428367 | ||||||||
| Practice Location | |||||||||
| Address1: | 2743B HWY 35N | ||||||||
| Address2: | |||||||||
| City: | MIMBRES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755363990 | ||||||||
| FaxNumber: | 5755363991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 11/24/2008 | ||||||||
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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 | PA2007-0006 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | NM300066 | 01 | MEDICARE PTAN | OTHER | 57372764 | 05 | NM | MEDICAID |