Healthcare Provider Details

I. General information

NPI: 1902335102
Provider Name (Legal Business Name): SANDIA FOOT AND ANKLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8224 LOUISIANA BLVD NE STE C
ALBUQUERQUE NM
87113-2108
US

IV. Provider business mailing address

8224 LOUISIANA BLVD NE STE C
ALBUQUERQUE NM
87113-2108
US

V. Phone/Fax

Practice location:
  • Phone: 505-506-2503
  • Fax:
Mailing address:
  • Phone: 505-506-2503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number290
License Number StateNM

VIII. Authorized Official

Name: JILL REYNOLDS
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 505-226-1800