Healthcare Provider Details

I. General information

NPI: 1205436920
Provider Name (Legal Business Name): BENJAMIN CLIFFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 DR MARTIN LUTHER KING JR AVE NE STE 301
ALBUQUERQUE NM
87102-3668
US

IV. Provider business mailing address

933 BRADBURY DR SE STE 2222
ALBUQUERQUE NM
87106-4375
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-7090
  • Fax: 505-727-9590
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2020-0107
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: