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General NPI Number Information
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NPI Number | 1417657594
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Entity Type | Individual
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Provider Name | PETER DILLON GARDNER ALAM
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Gender | Male
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Dates
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Enumeration Date | 03/07/2023
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Last Update Date | 07/18/2023
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Provider Practice Location Address
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Address Line | 1224 NAKOMIS DR NE UNIT H
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City | ALBUQUERQUE
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State | NM
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Zip | 87112-6047
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Country | US
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Telephone | 832-512-5120
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Fax |
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Provider Business Mailing Address
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Address Line | 20747 CRANFIELD DR
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City | KATY
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State | TX
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Zip | 77450-2703
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Country | US
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Telephone | 832-512-5120
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT22024
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License Number State | NM
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