Provider Demographics
NPI:1861473803
Name:KWAN, ALBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:M
Last Name:KWAN
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 1:1820 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4024
Mailing Address - Country:US
Mailing Address - Phone:575-762-2207
Mailing Address - Fax:575-762-7108
Practice Address - Street 1:1820 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4024
Practice Address - Country:US
Practice Address - Phone:575-762-2207
Practice Address - Fax:575-762-7108
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM89340208600000X
NM89-340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM020045902OtherRAILROAD MEDICARE
NM10585Medicaid
NM020045902OtherRAILROAD MEDICARE
NM10585Medicaid