Healthcare Provider Details

I. General information

NPI: 1952047029
Provider Name (Legal Business Name): PEGGY NODERAMA MACASIEB APRN-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 FIRST PLAZA CTR NW STE 62
ALBUQUERQUE NM
87102-6543
US

IV. Provider business mailing address

5981 JEFFERSON ST NE STE A
ALBUQUERQUE NM
87109-3457
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4800
  • Fax:
Mailing address:
  • Phone: 505-370-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF0522055
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0522055
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: