Provider Demographics
NPI:1336728104
Name:ANZALDUA, ADRIAN ALBERTO
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:ALBERTO
Last Name:ANZALDUA
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 1:1588 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-3232
Mailing Address - Country:US
Mailing Address - Phone:254-717-2445
Mailing Address - Fax:
Practice Address - Street 1:2400 TUCKER AVENUE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program