Provider Demographics
NPI:1407171408
Name:SANDIA PLASTIC SURGERY, PC
Entity Type:Organization
Organization Name:SANDIA PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:WH
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-842-0066
Mailing Address - Street 1:801 ENCINO PLACE NE
Mailing Address - Street 2:SUITE D7
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102
Mailing Address - Country:US
Mailing Address - Phone:505-842-0066
Mailing Address - Fax:505-842-9325
Practice Address - Street 1:801 ENCINO PLACE NE
Practice Address - Street 2:SUITE D7
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-842-0066
Practice Address - Fax:505-842-9325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-01
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0451208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty