Healthcare Provider Details

I. General information

NPI: 1750355350
Provider Name (Legal Business Name): SANDRA F PENN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 1ST ST NW
ALBUQUERQUE NM
87102-1529
US

IV. Provider business mailing address

1117 PRINCETON DR NE
ALBUQUERQUE NM
87106-2614
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4644
  • Fax:
Mailing address:
  • Phone: 505-266-2492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number80-78
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: