Healthcare Provider Details

I. General information

NPI: 1568797207
Provider Name (Legal Business Name): DR. Y'SHUA YISRAEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2501
US

IV. Provider business mailing address

9500 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111-2501
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4224
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2300
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: