Healthcare Provider Details

I. General information

NPI: 1063907913
Provider Name (Legal Business Name): JOSHUA BLANKMAN DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2018
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CENTRAL AVE SW STE E
ALBUQUERQUE NM
87104-1183
US

IV. Provider business mailing address

1700 CENTRAL AVE SW STE E
ALBUQUERQUE NM
87104-1183
US

V. Phone/Fax

Practice location:
  • Phone: 505-219-4310
  • Fax: 505-219-4296
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1228
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: