Healthcare Provider Details

I. General information

NPI: 1770170219
Provider Name (Legal Business Name): TANA ELIZABETH BEVERWYK-ABOUDA CPT, EIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 12/30/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 N RIVERSIDE DR STE C
ESPANOLA NM
87532-2620
US

IV. Provider business mailing address

33-A SANTA FE COUNTY ROAD 119-N
SANTA FE NM
87506
US

V. Phone/Fax

Practice location:
  • Phone: 505-927-8516
  • Fax:
Mailing address:
  • Phone: 505-927-8516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number798784
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: