Healthcare Provider Details

I. General information

NPI: 1205790375
Provider Name (Legal Business Name): ANDREW M NULL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 SOMDG 224 WEST D.L. INGRAM AVE, BLDG. 1408
CANNON AFB NM
88103
US

IV. Provider business mailing address

27 SOMDG 224 WEST D.L. INGRAM AVE, BLDG. 1408
CANNON AFB NM
88103
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-2778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: