Healthcare Provider Details

I. General information

NPI: 1619197316
Provider Name (Legal Business Name): EUGENE W. WASYLENKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7012 VISTA DEL ARROYO AVE NE
ALBUQUERQUE NM
87109-2933
US

IV. Provider business mailing address

7012 VISTA DEL ARROYO AVE NE
ALBUQUERQUE NM
87109-2933
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-7813
  • Fax:
Mailing address:
  • Phone: 505-884-7813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberNM 72-245
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: