MEDICARE: DAVITA ADANUVOR

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	363LA2100X	Acute Care Nurse Practitioner	CNP-02206	NM
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP61160839	WA

General Provider Information

NPI Number	:	1629417621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVITA ADANUVOR

Provider Business Mailing Address
First Line	:	807 CALLE CHAMISAL
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2976
Country	:	US
Telephone Number	:	505-372-4511
Fax Number	:

Provider Business Practice Location Address
First Line	:	807 CALLE CHAMISAL
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2976
Country	:	US
Telephone Number	:	505-372-4511
Fax Number	:

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

Provider Enumeration Date	:	06/24/2013
Last Update Date	:	04/26/2023

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Directions to “ DAVITA ADANUVOR ” Practice Location

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