Healthcare Provider Details

I. General information

NPI: 1245798586
Provider Name (Legal Business Name): BERNARDO BLACK FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 02/16/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WSTF/NASA CLINIC 12600 NASA ROAD BLDG. 104-E
LAS CRUCES NM
88012-1298
US

IV. Provider business mailing address

WSTF/NASA CLINIC 12600 NASA ROAD BLDG. 104-E
LAS CRUCES NM
88012-1298
US

V. Phone/Fax

Practice location:
  • Phone: 575-524-5213
  • Fax:
Mailing address:
  • Phone: 575-524-5213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number55487
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: