Healthcare Provider Details

I. General information

NPI: 1922077239
Provider Name (Legal Business Name): ALLAN G BENDORF CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WALTER ST NE SUITE 409
ALBUQUERQUE NM
87102-2534
US

IV. Provider business mailing address

PO BOX 30585
ALBUQUERQUE NM
87190-0585
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-7729
  • Fax: 505-243-4804
Mailing address:
  • Phone: 505-243-7729
  • Fax: 505-243-4804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR17930
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: