Healthcare Provider Details

I. General information

NPI: 1861918476
Provider Name (Legal Business Name): PETER SHENK KOONTZ MSN, RN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC06 3870 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-7000
US

IV. Provider business mailing address

MSC06 3870 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-277-3136
  • Fax: 505-277-2020
Mailing address:
  • Phone: 505-277-3136
  • Fax: 505-277-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71010058A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number79927
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number79927
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: