Provider Demographics
NPI:1043728249
Name:BAZARON, DMITRIY VLADIMIROVICH (CNP)
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:VLADIMIROVICH
Last Name:BAZARON
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 TRANSPORT ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4382
Mailing Address - Country:US
Mailing Address - Phone:505-262-7110
Mailing Address - Fax:505-262-7308
Practice Address - Street 1:2901 TRANSPORT ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4382
Practice Address - Country:US
Practice Address - Phone:505-255-1717
Practice Address - Fax:505-266-9362
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03476363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily