Healthcare Provider Details

I. General information

NPI: 1720668726
Provider Name (Legal Business Name): ALEXANDRA MANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 10/12/2025
Certification Date: 10/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

13001 ROMA AVE NE
ALBUQUERQUE NM
87123-1635
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2111
  • Fax:
Mailing address:
  • Phone: 505-412-0120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2021-0590
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: