Healthcare Provider Details

I. General information

NPI: 1265923080
Provider Name (Legal Business Name): NATHALY CORTEZ BAZAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LEAD AVE SE
ALBUQUERQUE NM
87106-5215
US

IV. Provider business mailing address

PO BOX 26666
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-224-7000
  • Fax: 505-224-7292
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD2024-0180
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: