Healthcare Provider Details

I. General information

NPI: 1396980165
Provider Name (Legal Business Name): RENEE E THOMPSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 MARLA DR NE
ALBUQUERQUE NM
87109-1937
US

IV. Provider business mailing address

4201 MARLA DR NE
ALBUQUERQUE NM
87109-1937
US

V. Phone/Fax

Practice location:
  • Phone: 505-401-2945
  • Fax:
Mailing address:
  • Phone: 505-401-2945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2006-0100
License Number StateNM

VIII. Authorized Official

Name: RENEE E THOMPSON
Title or Position: SOLE PRIORETOR
Credential: MD
Phone: 505-401-2945