Healthcare Provider Details

I. General information

NPI: 1376569921
Provider Name (Legal Business Name): ALBUQUERQUE UROLOGY ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

IV. Provider business mailing address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-3991
  • Fax: 505-243-8405
Mailing address:
  • Phone: 505-242-3991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number6682460001
License Number StateNM

VIII. Authorized Official

Name: JONATHAN EDWARD LACKNER
Title or Position: PARTNER / M.D.
Credential: M.D.
Phone: 505-242-3991