Healthcare Provider Details

I. General information

NPI: 1235464710
Provider Name (Legal Business Name): MR. TOM ANTHONY PANTANO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 SILVER AVE SE
ALBUQUERQUE NM
87102-3637
US

IV. Provider business mailing address

715 SILVER AVE SE
ALBUQUERQUE NM
87102-3637
US

V. Phone/Fax

Practice location:
  • Phone: 505-850-2933
  • Fax:
Mailing address:
  • Phone: 505-850-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberCNP00214
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberCNP00214
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: