=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891380085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDIA FOOT & ANKLE OF ALBUQUERQUE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2021
-----------------------------------------------------
Last Update Date | 02/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8300 CARMEL AVE NE STE 501
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87122-3125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-717-1274
-----------------------------------------------------
Fax | 505-717-1879
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8300 CARMEL AVE NE STE 501
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87122-3125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-717-1274
-----------------------------------------------------
Fax | 505-717-1879
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARK TENNY
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 505-717-1274
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------