Healthcare Provider Details

I. General information

NPI: 1275114126
Provider Name (Legal Business Name): DIANDRA LITTLE DOG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2100
US

IV. Provider business mailing address

3001 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2100
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-7000
  • Fax:
Mailing address:
  • Phone: 505-994-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2026-0726
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: