Healthcare Provider Details

I. General information

NPI: 1841782877
Provider Name (Legal Business Name): JENNIFER PANTOJA CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 GOLF COURSE RD SE STE 201
RIO RANCHO NM
87124-4731
US

IV. Provider business mailing address

4201 CENTRAL AVE NW STE K3
ALBUQUERQUE NM
87105-1647
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-6449
  • Fax: 505-545-6731
Mailing address:
  • Phone: 505-508-1739
  • Fax: 505-554-1106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP03591
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: