Healthcare Provider Details

I. General information

NPI: 1114708021
Provider Name (Legal Business Name): NATHAN VASQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 10/09/2023
Certification Date: 10/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8510 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2307
US

IV. Provider business mailing address

5082 KENWOOD RD
LAS CRUCES NM
88012-7426
US

V. Phone/Fax

Practice location:
  • Phone: 505-348-0066
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00010015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: