Healthcare Provider Details

I. General information

NPI: 1114414810
Provider Name (Legal Business Name): PRANAMYA SURI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LOUISIANA BLVD NE STE 410
ALBUQUERQUE NM
87110-5412
US

IV. Provider business mailing address

2100 LOUISIANA BLVD NE STE 410
ALBUQUERQUE NM
87110-5412
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-4300
  • Fax: 505-724-4384
Mailing address:
  • Phone: 505-724-4300
  • Fax: 505-724-4384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD2024-0407
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberD94652
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: