Individual
VANESSA D LICONA SANJUAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
500 WALTER ST NE, STE 401, ALBUQUERQUE, NM 87102-2563
(505) 727-5910
(505) 727-5939
Mailing address
500 WALTER ST NE, STE 401, ALBUQUERQUE, NM 87102-2563
(505) 727-5910
(505) 727-5939
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
MD2012-0867
NM
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
98305522
—
NM
Enumeration date
07/26/2010
Last updated
04/19/2017
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