Healthcare Provider Details

I. General information

NPI: 1396179388
Provider Name (Legal Business Name): TRENTON BURGESS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 BROADMOOR BLVD NE DEPT OF
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: 505-944-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2022-1051
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: