Provider Demographics
NPI:1992520357
Name:BRENA, JORGE LUIS (NP)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:BRENA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:JORGE
Other - Middle Name:LUIS
Other - Last Name:BRENA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5122 ENSENADA PL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-3820
Mailing Address - Country:US
Mailing Address - Phone:505-670-6742
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-20
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM82477363L00000X
NM87643363LG0600X
NM11111363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology