Healthcare Provider Details

I. General information

NPI: 1124891650
Provider Name (Legal Business Name): TWC ABQ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 SAN MATEO BLVD NE STE F2
ALBUQUERQUE NM
87109-3536
US

IV. Provider business mailing address

6300 SAN MATEO BLVD NE STE F2
ALBUQUERQUE NM
87109-3536
US

V. Phone/Fax

Practice location:
  • Phone: 505-818-1930
  • Fax: 505-336-5399
Mailing address:
  • Phone: 505-818-1930
  • Fax: 505-336-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK ANTHONY CERNA JR.
Title or Position: PRESIDENT
Credential:
Phone: 505-818-1930