Healthcare Provider Details

I. General information

NPI: 1780286344
Provider Name (Legal Business Name): ANDRE MICHAEL CHEPETAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 08/25/2024
Certification Date: 08/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6709 ACADEMY RD NE STE A
ALBUQUERQUE NM
87109-3363
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-5347
US

V. Phone/Fax

Practice location:
  • Phone: 505-308-3145
  • Fax: 505-308-3147
Mailing address:
  • Phone: 469-291-3369
  • Fax: 214-645-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1029382
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number64039
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: