Healthcare Provider Details

I. General information

NPI: 1720761695
Provider Name (Legal Business Name): JESSE DANIEL ACOSTA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 GOLF COURSE RD NW
ALBUQUERQUE NM
87114-5019
US

IV. Provider business mailing address

2425 CAMINO SEVILLE SE
RIO RANCHO NM
87124-8851
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-2000
  • Fax:
Mailing address:
  • Phone: 505-417-1397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number75124
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: