Healthcare Provider Details

I. General information

NPI: 1295733467
Provider Name (Legal Business Name): WENDELL WESTON SUMNER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10110 SPAIN RD NE
ALBUQUERQUE NM
87111-1965
US

IV. Provider business mailing address

10110 SPAIN RD NE
ALBUQUERQUE NM
87111-1965
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-5065
  • Fax: 505-298-2731
Mailing address:
  • Phone: 505-294-5065
  • Fax: 505-298-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA-569-71
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: