Healthcare Provider Details

I. General information

NPI: 1215987110
Provider Name (Legal Business Name): MEGAN JILL BOOKHOUT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN JILL MUNDY PA

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2745
US

IV. Provider business mailing address

2121 E HARMONY RD STE 330
FORT COLLINS CO
80528-3403
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3120
  • Fax: 505-272-8060
Mailing address:
  • Phone: 702-215-8789
  • Fax: 970-221-3564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2013-0023
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0007045
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: