Provider Demographics
NPI:1710451836
Name:THIYAGARAJAN, SOPHIA (CNP)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:THIYAGARAJAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-232-1617
Mailing Address - Fax:505-262-7729
Practice Address - Street 1:2901 TRANSPORT ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4382
Practice Address - Country:US
Practice Address - Phone:505-262-7451
Practice Address - Fax:505-262-7870
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM54671363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96487810Medicaid