Healthcare Provider Details

I. General information

NPI: 1841384237
Provider Name (Legal Business Name): AMY DAVIS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PMG PEDIATRIC SURGICAL GROUP 201 CEDAR SE SUITE 503
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-224-7478
  • Fax: 505-224-7479
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR19892
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: