Healthcare Provider Details

I. General information

NPI: 1114055365
Provider Name (Legal Business Name): BOSHA A GORDON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 05/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MEDICAL ARTS AVE NE # UNM
ALBUQUERQUE NM
87102-2708
US

IV. Provider business mailing address

2829 INDIANA ST NE
ALBUQUERQUE NM
87110-3427
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5132
  • Fax:
Mailing address:
  • Phone: 505-508-1304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP00393
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: