Provider Demographics
NPI:1164435673
Name:ANDRADE, AEDRA D (MD)
Entity Type:Individual
Prefix:
First Name:AEDRA
Middle Name:D
Last Name:ANDRADE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AEDRA
Other - Middle Name:DAWN
Other - Last Name:WENGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1504 FAIRWAY CIR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4937
Mailing Address - Country:US
Mailing Address - Phone:505-722-5008
Mailing Address - Fax:505-722-5008
Practice Address - Street 1:610 N 5TH ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5306
Practice Address - Country:US
Practice Address - Phone:505-863-3120
Practice Address - Fax:505-863-2691
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM2003-0155207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16657055Medicaid
I0464Medicare UPIN