Healthcare Provider Details

I. General information

NPI: 1669929485
Provider Name (Legal Business Name): AVRA SOPHIA SASKIA LAARAKKER M.D, M.SC, B.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC PLASTIC SURGERY 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

MSC PLASTIC SURGERY 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4264
  • Fax: 505-272-4264
Mailing address:
  • Phone: 505-272-4264
  • Fax: 505-272-4264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberRTL
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number222273
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD486085
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: