Healthcare Provider Details

I. General information

NPI: 1790959203
Provider Name (Legal Business Name): STEPHANIE HUE PENDERGRASS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STEPHANIE JANE HUE MD

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11120 MALAGUENA LN NE
ALBUQUERQUE NM
87111-6861
US

IV. Provider business mailing address

11120 MALAGUENA LN NE
ALBUQUERQUE NM
87111-6861
US

V. Phone/Fax

Practice location:
  • Phone: 505-401-8956
  • Fax:
Mailing address:
  • Phone: 505-401-8956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2014-0832
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: