Healthcare Provider Details

I. General information

NPI: 1770634982
Provider Name (Legal Business Name): SUSAN LAYNE LEWIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108-4729
US

IV. Provider business mailing address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108-4729
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-3542
  • Fax: 505-262-7394
Mailing address:
  • Phone: 505-262-3542
  • Fax: 505-262-7394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2007-0105
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: