Healthcare Provider Details

I. General information

NPI: 1497467518
Provider Name (Legal Business Name): DANIEL SULTAN HAIDER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 02/09/2024
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 COORS BLVD NW
ALBUQUERQUE NM
87120-3699
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-596-2200
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2023-0278
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: