Provider Demographics
NPI:1871915702
Name:LAVALLEY, JONATHON MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:MICHAEL
Last Name:LAVALLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2245
Mailing Address - Country:US
Mailing Address - Phone:505-363-5126
Mailing Address - Fax:
Practice Address - Street 1:1423 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2245
Practice Address - Country:US
Practice Address - Phone:505-287-6500
Practice Address - Fax:505-287-5393
Is Sole Proprietor?:No
Enumeration Date:2014-01-12
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2013-0089363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant