Healthcare Provider Details

I. General information

NPI: 1609467182
Provider Name (Legal Business Name): KATRINA S OLIVAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 03/14/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9640 MENAUL BLVD NE
ALBUQUERQUE NM
87112-2217
US

IV. Provider business mailing address

3209 WALSH LOOP SE
RIO RANCHO NM
87124-2963
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-4167
  • Fax:
Mailing address:
  • Phone: 505-934-1152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number62694
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: