Healthcare Provider Details

I. General information

NPI: 1447976220
Provider Name (Legal Business Name): SEAN M DIENER NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 HARPER DR NE
ALBUQUERQUE NM
87109-3587
US

IV. Provider business mailing address

11428 ACADEMY RIDGE RD NE
ALBUQUERQUE NM
87111-6896
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8888
  • Fax:
Mailing address:
  • Phone: 801-759-9598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number70314
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: