Provider Demographics
NPI:1366289134
Name:SEDILLO, STANLEY ANTHONY
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:ANTHONY
Last Name:SEDILLO
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 1:5044 FLAMINGO AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1290
Mailing Address - Country:US
Mailing Address - Phone:505-220-0962
Mailing Address - Fax:
Practice Address - Street 1:5044 FLAMINGO AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1290
Practice Address - Country:US
Practice Address - Phone:505-220-0962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM58852171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications