Healthcare Provider Details

I. General information

NPI: 1972109742
Provider Name (Legal Business Name): ANDREWE BACA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 11/13/2021
Certification Date: 11/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC08 4700 01 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-2719
US

IV. Provider business mailing address

12 CALLE CRISTOVAL
SANTA FE NM
87507-3716
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3414
  • Fax: 505-272-8239
Mailing address:
  • Phone:
  • 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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: