Healthcare Provider Details

I. General information

NPI: 1780988923
Provider Name (Legal Business Name): NICOLE LAROE STROMBERG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 DENNIS CHAVEZ BLVD SW ATRISCO HERITAGE CLINIC,
ALBUQUERQUE NM
87121-5498
US

IV. Provider business mailing address

10800 DENNIS CHAVEZ BLVD SW ATRISCO HERITAGE CLINIC
ALBUQUERQUE NM
87121-5498
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6009
  • Fax:
Mailing address:
  • Phone: 505-272-6009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2013-0066
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: