Healthcare Provider Details

I. General information

NPI: 1902034879
Provider Name (Legal Business Name): SCOTT RYAN JEANSONNE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 DON PASQUAL RD NW
LOS LUNAS NM
87031-8841
US

IV. Provider business mailing address

PO BOX 912678
DENVER CO
80291-2678
US

V. Phone/Fax

Practice location:
  • Phone: 505-873-7400
  • Fax:
Mailing address:
  • Phone: 505-241-5182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA-1580-10
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: