Healthcare Provider Details

I. General information

NPI: 1194385096
Provider Name (Legal Business Name): JASON TYLER DUNN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-2672
US

IV. Provider business mailing address

5111 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-2672
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-9900
  • Fax: 505-271-0217
Mailing address:
  • Phone: 505-271-9900
  • Fax: 505-271-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD471
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: