Healthcare Provider Details

I. General information

NPI: 1700151107
Provider Name (Legal Business Name): ALISHA JABAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE ACC THIRD FLOOR
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

2211 LOMAS BLVD NE ACC THIRD FLOOR
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5551
  • Fax: 505-272-6845
Mailing address:
  • Phone: 505-272-5551
  • Fax: 505-272-6845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAB7003469B1193
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: