Healthcare Provider Details

I. General information

NPI: 1669515425
Provider Name (Legal Business Name): JANE ANDERSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 CALLE DE ALAMO NW
ALBUQUERQUE NM
87104-3139
US

IV. Provider business mailing address

3109 CALLE DE ALAMO NW
ALBUQUERQUE NM
87104-3139
US

V. Phone/Fax

Practice location:
  • Phone: 505-345-7612
  • Fax: 505-341-0176
Mailing address:
  • Phone: 505-345-7612
  • Fax: 505-341-0176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number784
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: