Healthcare Provider Details

I. General information

NPI: 1164182473
Provider Name (Legal Business Name): ADRIAN ALEXIS ANDERSON APRN, NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ADRIAN ALEXIS DIAZ RN

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

3003 ADAMS ST NE APT M60
ALBUQUERQUE NM
87110-8013
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2111
  • Fax:
Mailing address:
  • Phone: 708-606-8523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number67058
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number67058
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number67058
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0997231
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: