Healthcare Provider Details

I. General information

NPI: 1154151041
Provider Name (Legal Business Name): MATTHEW BOUWER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 WILLIAM ST SE
ALBUQUERQUE NM
87102-4661
US

IV. Provider business mailing address

PO BOX 27561 DEPT #31116
ALBUQUERQUE NM
87125-7561
US

V. Phone/Fax

Practice location:
  • Phone: 505-768-5450
  • Fax:
Mailing address:
  • Phone: 505-873-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61585237
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: