Healthcare Provider Details

I. General information

NPI: 1407199052
Provider Name (Legal Business Name): ANDREW GUAJARDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2013
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC07 4040 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131
US

IV. Provider business mailing address

10 S WOLFE ST APT. 203
BALTIMORE MD
21231-1903
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3053
  • Fax: 505-925-0546
Mailing address:
  • Phone: 845-401-5251
  • 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 Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: