Provider Demographics
NPI:1063271229
Name:REGAN, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:REGAN
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 1:87 ANAYA RD
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-8209
Mailing Address - Country:US
Mailing Address - Phone:505-463-1970
Mailing Address - Fax:
Practice Address - Street 1:1415 VAN CLEAVE RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-3437
Practice Address - Country:US
Practice Address - Phone:505-463-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator