Provider Demographics
NPI:1619955176
Name:ANDRADE, LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:ANDRADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 NIZHONI BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5757
Mailing Address - Country:US
Mailing Address - Phone:505-722-6603
Mailing Address - Fax:505-722-6111
Practice Address - Street 1:517 NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5757
Practice Address - Country:US
Practice Address - Phone:505-722-6603
Practice Address - Fax:505-722-6111
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0154207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM201042926OtherPRESBYTERIAN HEALTH/SALUD
NM77609867Medicaid
NMNM009L08OtherBC/BS
NM11491288OtherCAQH
AZ806226OtherAHCCCS
NMQMP000003701894OtherMOLINA
85031326887301A162OtherCHAMPUS
NMNM009L08OtherBC/BS
NMQMP000003701894OtherMOLINA