1194800292 NPI number — MISS KRISTA ELENA BARRETT LISW

Table of content: MICHELLE M BUIKEMA NP-C (NPI 1760757280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194800292 NPI number — MISS KRISTA ELENA BARRETT LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARRETT
Provider First Name:
KRISTA
Provider Middle Name:
ELENA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1194800292
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51834
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87181-1834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-888-1121
Provider Business Mailing Address Fax Number:
505-797-0310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2418 MILES RD SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87106-3224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-888-1121
Provider Business Practice Location Address Fax Number:
505-797-0310
Provider Enumeration Date:
10/26/2006

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: 1041C0700X , with the licence number:  I-3313 , 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: R4817 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM00JA67 . This is a "NM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM100173 . This is a "VALUE OPTIONS OF NM" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 10007314 . This is a "LOVELACE HEALTH PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 168841 . This is a "MANAGED HEALTH NETWORK" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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