Healthcare Provider Details

I. General information

NPI: 1417122862
Provider Name (Legal Business Name): AUDREY WELLS GURULE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14101 FAIRVIEW DR STE 300
BURNSVILLE MN
55337-2537
US

IV. Provider business mailing address

6500 JEFFERSON ST NE
ALBUQUERQUE NM
87109-3489
US

V. Phone/Fax

Practice location:
  • Phone: 952-892-2650
  • Fax: 952-892-2654
Mailing address:
  • Phone: 505-843-8758
  • Fax: 505-843-8759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number2003020150
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License NumberRS20080525
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2003020150
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: