Healthcare Provider Details

I. General information

NPI: 1952136285
Provider Name (Legal Business Name): ASHTON NICHOLAS KOONS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4808
US

IV. Provider business mailing address

4201 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4808
US

V. Phone/Fax

Practice location:
  • Phone: 505-717-1332
  • Fax:
Mailing address:
  • Phone: 505-717-1332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2024-0813
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: