Healthcare Provider Details

I. General information

NPI: 1669451852
Provider Name (Legal Business Name): TIMOTHY D. KRENIK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8210 LOUISIANA BLVD. NE SUITE C
ALBUQUERQUE NM
87113-1761
US

IV. Provider business mailing address

8210 LOUISIANA BLVD. NE SUITE C
ALBUQUERQUE NM
87113-1761
US

V. Phone/Fax

Practice location:
  • Phone: 505-858-1222
  • Fax: 505-858-1224
Mailing address:
  • Phone: 505-858-1222
  • Fax: 505-858-1224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2003-0018
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: