Healthcare Provider Details

I. General information

NPI: 1508994559
Provider Name (Legal Business Name): ANDREA CORMIER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 SAN MATEO BLVD NE
ALBUQUERQUE NM
87108-1434
US

IV. Provider business mailing address

1617 STANFORD DR SE
ALBUQUERQUE NM
87106-3308
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-5976
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number97-PA24
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: