Provider Demographics
NPI:1952293466
Name:EVOLVEABQ PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:EVOLVEABQ PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FATEMI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:505-272-3120
Mailing Address - Street 1:4550 EUBANK BLVD NE STE 108
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4550 EUBANK BLVD NE STE 108
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2565
Practice Address - Country:US
Practice Address - Phone:505-616-0915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-18
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty