Healthcare Provider Details

I. General information

NPI: 1538821913
Provider Name (Legal Business Name): KATHERINE NICOLE OBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 ELM ST NE
ALBUQUERQUE NM
87102-2512
US

IV. Provider business mailing address

4101 INDIAN SCHOOL RD NE STE 110
ALBUQUERQUE NM
87110-3991
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-5155
  • Fax:
Mailing address:
  • Phone: 505-727-5785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: