Healthcare Provider Details

I. General information

NPI: 1386950277
Provider Name (Legal Business Name): TIENEKA MARY BAKER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIENEKA MARY BULTHUIS D.O.

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4051
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number0102203053
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0102203053
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA-2346-20
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: