Healthcare Provider Details

I. General information

NPI: 1629352778
Provider Name (Legal Business Name): TONY F GREGORY LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 ELM ST NE
ALBUQUERQUE NM
87102-2512
US

IV. Provider business mailing address

502 ELM ST NE
ALBUQUERQUE NM
87102-2512
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1000
  • Fax: 505-843-2592
Mailing address:
  • Phone: 505-841-1000
  • Fax: 505-843-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL19518
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: