MEDICARE: MICA RYE DE SOUSA DORIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	G-1381	NM

General Provider Information

NPI Number	:	1568305787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICA RYE DE SOUSA DORIA

Provider Business Mailing Address
First Line	:	HEALTH SCIENCES CENTER, MSC09 5300, 1 UNIVERSITY OF NEW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87131
Country	:	US
Telephone Number	:	505-272-1936
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 MARBLE AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106
Country	:	US
Telephone Number	:	505-272-1936
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2026
Last Update Date	:	04/13/2026

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