Healthcare Provider Details

I. General information

NPI: 1144482860
Provider Name (Legal Business Name): HIGH DESERT NEPHROLOGY ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 S SECOND ST
GALLUP NM
87301-5881
US

IV. Provider business mailing address

1551 S SECOND ST
GALLUP NM
87301-5881
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-7993
  • Fax: 505-863-9406
Mailing address:
  • Phone: 505-863-7993
  • Fax: 505-863-9406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number80-00001863
License Number StateNM

VIII. Authorized Official

Name: OLADIPO A ADENIYI
Title or Position: OWNER
Credential: MD
Phone: 505-863-7993