Provider Demographics
NPI:1083857247
Name:BURBANO, ALICIA MICHELE
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:MICHELE
Last Name:BURBANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 JUAN TABO BLVD NE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3984
Mailing Address - Country:US
Mailing Address - Phone:505-298-1010
Mailing Address - Fax:505-298-3939
Practice Address - Street 1:3900 JUAN TABO BLVD NE
Practice Address - Street 2:SUITE 4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3984
Practice Address - Country:US
Practice Address - Phone:505-298-1010
Practice Address - Fax:505-298-3939
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2017-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-09642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61625728Medicaid
NM61625728Medicaid