Basic Information
| Provider Information | |||||||||
| NPI: | 1770225252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACEVEDO | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | LEON AQUINDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | MSC06 3500 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059254031 | ||||||||
| FaxNumber: | 5059254030 | ||||||||
| Practice Location | |||||||||
| Address1: | MSC06 3500 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059254031 | ||||||||
| FaxNumber: | 5059254030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2022 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | TD-00-153 | NM | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.