Healthcare Provider Details

I. General information

NPI: 1922977750
Provider Name (Legal Business Name): BRYAN ADAM VELASQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8616 MOCK HEATHER RD NW
ALBUQUERQUE NM
87120-4250
US

IV. Provider business mailing address

8616 MOCK HEATHER RD NW
ALBUQUERQUE NM
87120-4250
US

V. Phone/Fax

Practice location:
  • Phone: 505-410-9364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR57792
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: