Provider Demographics
NPI:1417657594
Name:ALAM, PETER DILLON GARDNER
Entity Type:Individual
Prefix:
First Name:PETER DILLON
Middle Name:GARDNER
Last Name:ALAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20747 CRANFIELD DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-2703
Mailing Address - Country:US
Mailing Address - Phone:832-512-5120
Mailing Address - Fax:
Practice Address - Street 1:1224 NAKOMIS DR NE UNIT H
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-6047
Practice Address - Country:US
Practice Address - Phone:832-512-5120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMAT220242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer