Healthcare Provider Details

I. General information

NPI: 1205146685
Provider Name (Legal Business Name): JAMIE SLADEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3160
  • Fax:
Mailing address:
  • Phone: 505-272-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2010-0077
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA054464
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: