Provider Demographics
NPI:1619942398
Name:ANG, KARLYN GANSEL (OD)
Entity Type:Individual
Prefix:
First Name:KARLYN
Middle Name:GANSEL
Last Name:ANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5443 WYOMING BLVD NE
Mailing Address - Street 2:STE 2
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3199
Mailing Address - Country:US
Mailing Address - Phone:505-332-2020
Mailing Address - Fax:505-332-8343
Practice Address - Street 1:5343 WYOMING BLVD NE
Practice Address - Street 2:SUITE 2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3199
Practice Address - Country:US
Practice Address - Phone:505-332-2020
Practice Address - Fax:505-332-8343
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000P1448Medicaid
NMT92017Medicare UPIN
NM000P1448Medicaid