Healthcare Provider Details

I. General information

NPI: 1467120592
Provider Name (Legal Business Name): KUNKEL PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
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 TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN KUNKEL
Title or Position: PHYSICIAN
Credential: MD
Phone: 505-299-4900