1639403777 NPI number — MS. KATIE E PETTIGREW-WEEMS MPT

Table of content: MS. KATIE E PETTIGREW-WEEMS MPT (NPI 1639403777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639403777 NPI number — MS. KATIE E PETTIGREW-WEEMS MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTIGREW-WEEMS
Provider First Name:
KATIE
Provider Middle Name:
E
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETTIGREW
Provider Other First Name:
KATIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639403777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 CENTRAL AVE SE
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87102-3656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-242-2294
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6330 RIVERSIDE PLAZA LN NW
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87120-2681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-312-7930
Provider Business Practice Location Address Fax Number:
505-717-2818
Provider Enumeration Date:
09/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3760 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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