Healthcare Provider Details

I. General information

NPI: 1578494381
Provider Name (Legal Business Name): DARREN M WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MADEIRA DR SE
ALBUQUERQUE NM
87108-2963
US

IV. Provider business mailing address

1809 NOTRE DAME DR NE
ALBUQUERQUE NM
87106-1011
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-1538
  • Fax: 505-243-5342
Mailing address:
  • Phone: 505-974-2461
  • Fax: 505-974-2461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number72201
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: