Healthcare Provider Details

I. General information

NPI: 1780350447
Provider Name (Legal Business Name): MICHAELA LEE GRANADOS BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC10 5550 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-3104
US

IV. Provider business mailing address

2838 CUERVO DR NE
ALBUQUERQUE NM
87110-3104
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4661
  • Fax: 505-272-0475
Mailing address:
  • Phone: 505-515-1023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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: