Healthcare Provider Details

I. General information

NPI: 1679884241
Provider Name (Legal Business Name): NATHANIEL WEST REDISKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY OF NEW MEXICO MSC11 6093
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

1509 VISTA LARGA CT NE
ALBUQUERQUE NM
87106-2646
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6225
  • Fax: 505-272-5184
Mailing address:
  • Phone: 414-403-6635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number52586
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberMD2015-0602
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: