Healthcare Provider Details

I. General information

NPI: 1245980648
Provider Name (Legal Business Name): ANDREW FATUROS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC10 5550 1 UNIVERSITY OF NEW MEXICO, MSC08 4700
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

4150 V ST # 1100
SACRAMENTO CA
95817-1460
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4661
  • Fax: 505-272-0475
Mailing address:
  • Phone: 916-734-2737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2025-0191
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: