Healthcare Provider Details

I. General information

NPI: 1619980257
Provider Name (Legal Business Name): NEW MEXICO VA HEALTHCARE SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

29 CHOLLA CREST DR
CEDAR CREST NM
87008-9454
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-286-8022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number91-PA01
License Number StateNM

VIII. Authorized Official

Name: MS. VICKI LYNN SONTAG
Title or Position: PHYSICIAN ASSISTANT
Credential:
Phone: 505-265-1711