Healthcare Provider Details

I. General information

NPI: 1003183187
Provider Name (Legal Business Name): KIMBERLEY B. OLDEWAGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 JACKIE ROAD STE 101 WESTSIDE FAMILY MEDICINE
RIO RANCHO NM
87124-1519
US

IV. Provider business mailing address

1350 JACKIE ROAD STE 101 WESTSIDE FAMILY MEDICINE
RIO RANCHO NM
87124-1519
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-7518
  • Fax: 505-892-9092
Mailing address:
  • Phone: 505-892-7518
  • Fax: 505-892-9092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2011-0041
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: