Healthcare Provider Details

I. General information

NPI: 1164333514
Provider Name (Legal Business Name): MR. ANDREW MATTHEW EDWARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CARLISLE BLVD NE STE 105
ALBUQUERQUE NM
87110-1680
US

IV. Provider business mailing address

136 CAMPBELL AVE
YORKVILLE NY
13495-1715
US

V. Phone/Fax

Practice location:
  • Phone: 505-633-8173
  • Fax:
Mailing address:
  • Phone: 315-269-2153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: