Basic Information
| Provider Information | |||||||||
| NPI: | 1144314519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7850 JEFFERSON ST NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058841114 | ||||||||
| FaxNumber: | 5053593010 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 GOLD AVE SW STE 1300 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057154610 | ||||||||
| FaxNumber: | 5052734671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2001128 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2083A0300X | 2001-128 | NM | N | 207RA0401X | 2001-128 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 62709356 | 05 | NM | MEDICAID |