Healthcare Provider Details

I. General information

NPI: 1477182889
Provider Name (Legal Business Name): JACQUELYN C. BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-0621
  • Fax:
Mailing address:
  • Phone: 505-272-0621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2020-0111
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: