Healthcare Provider Details

I. General information

NPI: 1306681275
Provider Name (Legal Business Name): ANTONIO BRICENO PARRA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/04/2024
Certification Date: 07/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8417 WASHINGTON PL NE STE A
ALBUQUERQUE NM
87113-1720
US

IV. Provider business mailing address

11447 MANZANO VISTA AVE SE
ALBUQUERQUE NM
87123-2975
US

V. Phone/Fax

Practice location:
  • Phone: 505-273-9453
  • Fax: 505-503-1619
Mailing address:
  • Phone: 407-990-3828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number55814
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: