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General NPI Number Information
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NPI Number | 1003657198
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Entity Type | Organization
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Legal Business Name | CALYX DERMATOLOGY LLC
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Dates
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Enumeration Date | 06/04/2024
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Last Update Date | 07/25/2024
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Provider Practice Location Address
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Address Line | 612 ENCINO PL NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-2602
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Country | US
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Telephone | 240-367-2980
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Fax |
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Provider Business Mailing Address
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Address Line | 5863 MAFRAQ AVE NW
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City | ALBUQUERQUE
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State | NM
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Zip | 87114-6071
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Country | US
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Telephone | 240-367-2980
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Fax |
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Authorized Official
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Title or Position | DERMATOLOGIST/MOHS SURGEON
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Name | DR. CATHERINE TCHANQUE-FOSSUO
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Credential | MD, MS, FAAD
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Telephone | 240-367-2980
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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