Healthcare Provider Details

I. General information

NPI: 1205147592
Provider Name (Legal Business Name): KETURA PREYA WISNER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 HARPER DR NE STE 410
ALBUQUERQUE NM
87109-3585
US

IV. Provider business mailing address

5700 HARPER DR NE STE 410
ALBUQUERQUE NM
87109-3585
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-7813
  • Fax: 505-843-6947
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA-2079-17
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberA-2079-17
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: