=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174256226
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENISE N SMALLWOOD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2022
-----------------------------------------------------
Last Update Date | 12/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10127 AVENIDA VISTA SOL NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87114-5903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-803-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10127 AVENIDA VISTA SOL NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87114-5903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------