Healthcare Provider Details

I. General information

NPI: 1679865844
Provider Name (Legal Business Name): PHYLLIS ESTES BERGMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 05/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2207 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-4117
US

IV. Provider business mailing address

PO BOX 64
CEDAR CREST NM
87008-0064
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-6131
  • Fax:
Mailing address:
  • Phone: 505-281-6131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberCNP 00742
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: