Healthcare Provider Details

I. General information

NPI: 1114976610
Provider Name (Legal Business Name): ANGELA Y WO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 TRANSPORT ST SE
ALBUQUERQUE NM
87106-4382
US

IV. Provider business mailing address

PO BOX 26028
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7097
  • Fax: 505-262-7636
Mailing address:
  • Phone: 505-232-1617
  • Fax: 505-226-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA07980200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD2012-0043
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: