Healthcare Provider Details

I. General information

NPI: 1295665446
Provider Name (Legal Business Name): MOBILE DERMATOLOGY PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 MENAUL BLVD NE STE 108
ALBUQUERQUE NM
87110-2842
US

IV. Provider business mailing address

3636 MENAUL BLVD NE STE 108
ALBUQUERQUE NM
87110-2842
US

V. Phone/Fax

Practice location:
  • Phone: 505-816-0159
  • Fax: 480-240-5931
Mailing address:
  • Phone: 505-816-0159
  • Fax: 480-240-5931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN HARRIS
Title or Position: OWNER
Credential: PA-C
Phone: 480-461-9822