Healthcare Provider Details

I. General information

NPI: 1780617357
Provider Name (Legal Business Name): LINDA KWIATKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 05/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 DR MARTIN LUTHER KING JR AVE NE SUITE 301
ALBUQUERQUE NM
87102-3661
US

IV. Provider business mailing address

715 DR MARTIN LUTHER KING JR AVE NE SUITE 301
ALBUQUERQUE NM
87102-3661
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7281
  • Fax: 505-262-7622
Mailing address:
  • Phone: 505-262-7281
  • Fax: 505-262-7622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number200159
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: