Healthcare Provider Details

I. General information

NPI: 1962066043
Provider Name (Legal Business Name): AUBREY HUERTA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3791 SOUTHERN BLVD SE STE 100
RIO RANCHO NM
87124-7417
US

IV. Provider business mailing address

3791 SOUTHERN BLVD SE STE 100
RIO RANCHO NM
87124-7417
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-9435
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2019-0042
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: