Healthcare Provider Details

I. General information

NPI: 1508368820
Provider Name (Legal Business Name): KENNETH PAUL SPART JR. NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2111
  • Fax:
Mailing address:
  • Phone: 501-548-1983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23710
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number65612
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number23710
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: