Healthcare Provider Details

I. General information

NPI: 1467673657
Provider Name (Legal Business Name): AUSTIN LYN MOEDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 NARCISCO ST NE
ALBUQUERQUE NM
87112-6536
US

IV. Provider business mailing address

1414 NARCISCO ST NE
ALBUQUERQUE NM
87112-6536
US

V. Phone/Fax

Practice location:
  • Phone: 505-293-3767
  • Fax: 505-293-1969
Mailing address:
  • Phone: 505-293-3767
  • Fax: 505-293-1969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number96-105
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: