Healthcare Provider Details

I. General information

NPI: 1295796480
Provider Name (Legal Business Name): VANCE EDWARD ZACHARY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 IRVING BLVD NW
ALBUQUERQUE NM
87114-5915
US

IV. Provider business mailing address

4420 IRVING BLVD NW
ALBUQUERQUE NM
87114-5915
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-6300
  • Fax: 505-727-9588
Mailing address:
  • Phone: 505-727-6300
  • Fax: 505-727-9588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG7610
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG7610
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2015-0091
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: