Healthcare Provider Details

I. General information

NPI: 1275953341
Provider Name (Legal Business Name): MICHAELA SAKUMURA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

PO BOX 5142
BRECKENRIDGE CO
80424-5142
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1234
  • Fax:
Mailing address:
  • Phone: 785-218-1835
  • 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 Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2017-0262
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: