Healthcare Provider Details

I. General information

NPI: 1770291239
Provider Name (Legal Business Name): ERICA N BACA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3949 CORRALES RD
CORRALES NM
87048-9348
US

IV. Provider business mailing address

3949 CORRALES RD STE 105
CORRALES NM
87048-9347
US

V. Phone/Fax

Practice location:
  • Phone: 505-805-2273
  • Fax: 505-422-4419
Mailing address:
  • Phone: 505-805-2273
  • Fax: 505-422-4419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number70213
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: