Healthcare Provider Details

I. General information

NPI: 1629542584
Provider Name (Legal Business Name): ALEXANDRA NINNEMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC 09-50401 1 UNIVERSITY OF NEW MEXICO (FPC)
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

PO BOX 4907
ALBUQUERQUE NM
87196-4907
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-8291
  • Fax: 505-272-1348
Mailing address:
  • Phone: 575-613-2580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD2023-1038
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2023-1038
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: