Healthcare Provider Details

I. General information

NPI: 1699669275
Provider Name (Legal Business Name): SANDIA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 JEFFERSON ST NE STE 700&800
ALBUQUERQUE NM
87109-2136
US

IV. Provider business mailing address

4700 JEFFERSON ST NE STE 700&800
ALBUQUERQUE NM
87109-2136
US

V. Phone/Fax

Practice location:
  • Phone: 505-437-5085
  • Fax:
Mailing address:
  • Phone: 505-437-5085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATHRYN WHITE
Title or Position: OWNER & MEDICAL DIRECTOR
Credential:
Phone: 505-463-2691