Healthcare Provider Details

I. General information

NPI: 1083857247
Provider Name (Legal Business Name): DR. ALICIA MICHELE BURBANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 04/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 JUAN TABO BLVD NE SUITE 4
ALBUQUERQUE NM
87111-3984
US

IV. Provider business mailing address

3900 JUAN TABO BLVD NE SUITE 4
ALBUQUERQUE NM
87111-3984
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-1010
  • Fax: 505-298-3939
Mailing address:
  • Phone: 505-298-1010
  • Fax: 505-298-3939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2013-0964
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: