Healthcare Provider Details

I. General information

NPI: 1720645310
Provider Name (Legal Business Name): AHMAD ABOU YASSINE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date: 01/17/2020
Reactivation Date: 02/19/2020

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2023-1071
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: