Healthcare Provider Details

I. General information

NPI: 1386296044
Provider Name (Legal Business Name): ANDREA GRANO CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 SAINT MICHAELS DR
SANTA FE NM
87505-7670
US

IV. Provider business mailing address

4485 GOLDEN EAGLE LOOP NE
RIO RANCHO NM
87144-7689
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-4901
  • Fax: 505-913-6426
Mailing address:
  • Phone: 505-614-6919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56915
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: