Healthcare Provider Details

I. General information

NPI: 1699764092
Provider Name (Legal Business Name): MANDA LOREE SLOAN-VAN BIBBER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MANDA LOREE SLOAN PAC

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/10/2021
Certification Date: 07/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-265-1711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number95-PA-15
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number572
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: