Healthcare Provider Details

I. General information

NPI: 1548264351
Provider Name (Legal Business Name): PREMIER ANESTHESIA OF NEW MEXICO, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 WYOMING BLVD NE
ALBUQUERQUE NM
87112-3855
US

IV. Provider business mailing address

PO BOX 52194 DEPT 987
PHOENIX AZ
85072-2194
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-9200
  • Fax:
Mailing address:
  • Phone: 575-532-7000
  • Fax: 575-532-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TRACY GORDON
Title or Position: OWNER
Credential: MD
Phone: 505-292-9200