Healthcare Provider Details

I. General information

NPI: 1568767267
Provider Name (Legal Business Name): RACHAEL MARIE BETTENCOURT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 HARPER DR NE
ALBUQUERQUE NM
87109-3589
US

IV. Provider business mailing address

PO BOX 26666 PRESBYTERIAN HEALTHCARE SERVICES - PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8282
  • Fax: 505-823-8275
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 9105626
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2011-0004
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: