Healthcare Provider Details

I. General information

NPI: 1073693842
Provider Name (Legal Business Name): RUBEN COLLADO CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 PEARL LOOP
BOSQUE FARMS NM
87068-9036
US

IV. Provider business mailing address

1835 PEARL LOOP
BOSQUE FARMS NM
87068-9036
US

V. Phone/Fax

Practice location:
  • Phone: 505-217-4150
  • Fax: 505-869-4907
Mailing address:
  • Phone: 505-217-4150
  • Fax: 505-869-4907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR17420
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: