Healthcare Provider Details

I. General information

NPI: 1144648627
Provider Name (Legal Business Name): RYAN P. KUNKEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 JUAN TABO BLVD NE STE 1C
ALBUQUERQUE NM
87111-2683
US

IV. Provider business mailing address

5203 JUAN TABO BLVD NE STE 1C
ALBUQUERQUE NM
87111-2683
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-4900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number11784145-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberNM2021-0692
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: