Healthcare Provider Details

I. General information

NPI: 1396148326
Provider Name (Legal Business Name): JIMMY FLOYD ANDAZOLA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2014
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10571 VISTA BELLA PL NW
ALBUQUERQUE NM
87114-3875
US

IV. Provider business mailing address

10571 VISTA BELLA PL NW
ALBUQUERQUE NM
87114-3875
US

V. Phone/Fax

Practice location:
  • Phone: 505-259-1133
  • Fax:
Mailing address:
  • Phone: 505-259-1133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2014-0051
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4505
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10494
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2014-0051
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3518
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7337
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: