Healthcare Provider Details

I. General information

NPI: 1619434164
Provider Name (Legal Business Name): MATTHEW GRINDSTAFF NNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

933 BRADBURY DR SE STE 2222
ALBUQUERQUE NM
87106-4375
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5551
  • Fax: 505-272-6845
Mailing address:
  • Phone: 505-414-1035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number1060421
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number54906
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: