1609270891 NPI number — PHYLLIS NADINE GONZALES

Table of content: (NPI 1609270891)

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".




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