Healthcare Provider Details

I. General information

NPI: 1487319620
Provider Name (Legal Business Name): MR. MARK ANTHONY CRESPIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10415 SANDY TRAIL RD SW
ALBUQUERQUE NM
87121-3626
US

IV. Provider business mailing address

10415 SANDY TRAIL RD SW
ALBUQUERQUE NM
87121-3626
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-5114
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: