Healthcare Provider Details

I. General information

NPI: 1710994058
Provider Name (Legal Business Name): MARTY DALE SURFACE DNP, FNP-BC, ACHPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 12/31/2024
Certification Date: 12/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RAYMOND G. MURPHY DEPT OF VETERANS AFFAIRS MC 1501 SAN PEDRO DRIVE SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

RAYMOND G. MURPHY DEPT OF VETERANS AFFAIRS MC 1501 SAN PEDRO DRIVE SE
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-6414
Mailing address:
  • Phone: 505-265-1711
  • Fax: 505-256-6414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number75910
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201250206NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: