Healthcare Provider Details

I. General information

NPI: 1629557079
Provider Name (Legal Business Name): CHRISTINE D PEASE HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 HARDWARE DR NE STE C-2
ALBUQUERQUE NM
87109-2021
US

IV. Provider business mailing address

4811 HARDWARE DR NE STE C-2
ALBUQUERQUE NM
87109-2021
US

V. Phone/Fax

Practice location:
  • Phone: 505-341-1300
  • Fax: 505-341-0956
Mailing address:
  • Phone: 505-341-1300
  • Fax: 505-341-0956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAD0911
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: