Healthcare Provider Details

I. General information

NPI: 1619279957
Provider Name (Legal Business Name): SUMMER WARDER-GABALDON PT,DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CENTRAL AVENUE SE SUITE D
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

600 CENTRAL AVENUE SE SUITE D
ALBUQUERQUE NM
87102
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-2294
  • Fax: 505-242-2917
Mailing address:
  • Phone: 505-242-2294
  • Fax: 505-242-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3897
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: