Healthcare Provider Details

I. General information

NPI: 1912731290
Provider Name (Legal Business Name): MOUNT SINAI MEDICAL SERVICES OF NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 MENAUL BLVD NE STE B550
ALBUQUERQUE NM
87112-2270
US

IV. Provider business mailing address

8500 MENAUL BLVD NE STE B550
ALBUQUERQUE NM
87112-2270
US

V. Phone/Fax

Practice location:
  • Phone: 505-595-3113
  • Fax: 505-200-9240
Mailing address:
  • Phone: 505-595-3113
  • Fax: 505-200-9240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LEO NWAOKWU
Title or Position: MANAGER
Credential:
Phone: 505-595-3113