Healthcare Provider Details

I. General information

NPI: 1992087969
Provider Name (Legal Business Name): CHRISTINA QUACK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA QUACK PA-C

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

933 BRADBURY DR SE STE 2222
ALBUQUERQUE NM
87106-4375
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2011-0026
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: