Healthcare Provider Details

I. General information

NPI: 1790280394
Provider Name (Legal Business Name): PATRICIA BLACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1219
US

IV. Provider business mailing address

4101 INDIAN SCHOOL RD NE STE 110
ALBUQUERQUE NM
87110-3991
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-7800
  • Fax:
Mailing address:
  • Phone: 505-727-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD2020-1147
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: