Healthcare Provider Details

I. General information

NPI: 1043841802
Provider Name (Legal Business Name): SAMANTHA MARIE PACHECO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 GEORGIA ST NE STE A1
ALBUQUERQUE NM
87110-1391
US

IV. Provider business mailing address

10405 SOLITUDE RD SW
ALBUQUERQUE NM
87121-5383
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-4012
  • Fax:
Mailing address:
  • Phone: 505-449-7024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number58850
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: