Healthcare Provider Details

I. General information

NPI: 1043610488
Provider Name (Legal Business Name): LEA ROTENBERG KOSHKIN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 JOURNAL CENTER BLVD., NE ADULT INTERNAL MEDICINE - 3RD FLOOR
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

PO BOX 26028
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-3212
  • Fax: 505-232-1532
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95001139
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-CNP57838
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: