Healthcare Provider Details

I. General information

NPI: 1134127772
Provider Name (Legal Business Name): KATE GOLDBLUM N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 MULBERRY NE
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

303 MULBERRY NE
ALBUQUERQUE NM
87106
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-9739
  • Fax: 505-842-0650
Mailing address:
  • Phone: 505-243-9739
  • Fax: 505-842-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0293583-22
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberR11582
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: