Healthcare Provider Details

I. General information

NPI: 1912850264
Provider Name (Legal Business Name): CODY MARSHWAN VASSAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 YALE BLVD SE
ALBUQUERQUE NM
87106-4817
US

IV. Provider business mailing address

1805 CHICOMA RD NE
RIO RANCHO NM
87144-2500
US

V. Phone/Fax

Practice location:
  • Phone: 505-295-3110
  • Fax:
Mailing address:
  • Phone: 708-916-6863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: