Healthcare Provider Details

I. General information

NPI: 1487319042
Provider Name (Legal Business Name): VIRIDIANA CHELSEA JEFFERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/03/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 PAN AMERICAN FWY
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

9100 PAN AMERICAN FWY NE
ALBUQUERQUE NM
87113-2144
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8282
  • Fax:
Mailing address:
  • Phone: 505-823-8282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: