Healthcare Provider Details

I. General information

NPI: 1396224390
Provider Name (Legal Business Name): MATTHEW DAVID TOTTER CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MONTGOMERY BLVD NE STE D201
ALBUQUERQUE NM
87109-1211
US

IV. Provider business mailing address

4600 MONTGOMERY BLVD NE STE D201
ALBUQUERQUE NM
87109-1211
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-0079
  • Fax:
Mailing address:
  • Phone: 505-884-0079
  • Fax: 505-884-3888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-75506
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53771
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: