Healthcare Provider Details

I. General information

NPI: 1063152999
Provider Name (Legal Business Name): HOLLY NICOLE SAUTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HOLLY NICOLE BACA

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MEDICAL ARTS AVE NE BLDG 2
ALBUQUERQUE NM
87102-2723
US

IV. Provider business mailing address

5836 ACADEMY CT NE
ALBUQUERQUE NM
87109-3877
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6110
  • Fax:
Mailing address:
  • Phone: 505-301-8563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0012
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: