Healthcare Provider Details

I. General information

NPI: 1053993618
Provider Name (Legal Business Name): RUSSELL RODOLFO DE PALMA CP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 04/23/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LEAD AVE SE STE 400
ALBUQUERQUE NM
87106-5214
US

IV. Provider business mailing address

1691 GALISTEO ST STE B
SANTA FE NM
87505-4781
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-0430
  • Fax: 505-820-2392
Mailing address:
  • Phone: 505-820-2390
  • Fax: 505-820-2392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: