Basic Information
| Provider Information | |||||||||
| NPI: | 1528230117 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYLIE | ||||||||
| FirstName: | LAURA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | SUITE 2222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721754 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 MEDICAL ARTS AVE NE # 4 | ||||||||
| Address2: | BUILDING 4, SUITE A, UNM SENIOR HEALTH | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052721754 | ||||||||
| FaxNumber: | 5053254594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2008 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA2007-0038 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.