1609270891 NPI number — PHYLLIS NADINE GONZALES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609270891 NPI number — PHYLLIS NADINE GONZALES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYLLIS NADINE GONZALES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609270891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 CAMINO ENCANTADO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87501-1039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-946-7677
Provider Business Mailing Address Fax Number:
505-986-1569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
219 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87501-1926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-946-7677
Provider Business Practice Location Address Fax Number:
505-986-1569
Provider Enumeration Date:
10/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALES
Authorized Official First Name:
PHYLLIS NADINE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-946-7677

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1318 , 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)

  • Identifier: 9408737 . This is a "PRIVATE HEALTHCARE SYSTEM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM00KL98 . This is a "BLUE CROSS BLUE SHIELD NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 12395202 . This is a "MULTIPLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 11NR0400X . This is a "NUCC TAXONOMY" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1821150756 . This is a "NPI TYPE 1" identifier . This identifiers is of the category "OTHER".
  • Identifier: 876338000 . This is a "REGENCE BCBS OREGON" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 5657319 . This is a "FIRST HEALTH" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 12248763 . This is a "CAQH" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 693017 . This is a "ACN GROUP" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com