Healthcare Provider Details

I. General information

NPI: 1710451836
Provider Name (Legal Business Name): SOPHIA THIYAGARAJAN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 TRANSPORT ST SE
ALBUQUERQUE NM
87106-4382
US

IV. Provider business mailing address

PO BOX 26028
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7451
  • Fax: 505-262-7870
Mailing address:
  • Phone: 505-232-1617
  • Fax: 505-262-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number54671
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: