1407171408 NPI number — SANDIA PLASTIC SURGERY, PC

Table of content: (NPI 1407171408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407171408 NPI number — SANDIA PLASTIC SURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANDIA PLASTIC SURGERY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407171408
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 ENCINO PLACE NE
Provider Second Line Business Mailing Address:
SUITE D7
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-842-0066
Provider Business Mailing Address Fax Number:
505-842-9325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 ENCINO PLACE NE
Provider Second Line Business Practice Location Address:
SUITE D7
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-842-0066
Provider Business Practice Location Address Fax Number:
505-842-9325
Provider Enumeration Date:
04/01/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHAN
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
W.H.
Authorized Official Title or Position:
OWNER/SOLE MEMBER
Authorized Official Telephone Number:
505-842-0066

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  MD2007-0451 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)