Healthcare Provider Details

I. General information

NPI: 1437366861
Provider Name (Legal Business Name): CYD EVANS P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11520 CORONADO AVE NE
ALBUQUERQUE NM
87122-2431
US

IV. Provider business mailing address

PO BOX 90685
ALBUQUERQUE NM
87199-0685
US

V. Phone/Fax

Practice location:
  • Phone: 505-238-6282
  • Fax: 505-856-7226
Mailing address:
  • Phone: 505-238-6282
  • Fax: 505-856-7226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number1314
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: