Healthcare Provider Details

I. General information

NPI: 1245800986
Provider Name (Legal Business Name): TYLER BOOTH FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVE NE
ALBUQUERQUE NM
87109-4397
US

IV. Provider business mailing address

2900 WISCONSIN ST NE
ALBUQUERQUE NM
87110-2458
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-8171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number64242
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: