Healthcare Provider Details

I. General information

NPI: 1831802230
Provider Name (Legal Business Name): ZIA PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2022
Last Update Date: 01/28/2023
Certification Date: 01/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 QUAIL TRL STE B
EDGEWOOD NM
87015-7197
US

IV. Provider business mailing address

104 QUAIL TRL STE B
EDGEWOOD NM
87015-7197
US

V. Phone/Fax

Practice location:
  • Phone: 505-926-9800
  • Fax:
Mailing address:
  • Phone: 505-926-9800
  • Fax: 505-926-9722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY AUTREY
Title or Position: CREDENTIALING
Credential:
Phone: 505-249-1369