Healthcare Provider Details

I. General information

NPI: 1366865560
Provider Name (Legal Business Name): DEITRA GATES CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

IV. Provider business mailing address

610 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2372
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-3991
  • Fax: 505-243-8405
Mailing address:
  • Phone: 505-242-3991
  • Fax: 505-243-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberCNS-00245
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: