Healthcare Provider Details

I. General information

NPI: 1982252383
Provider Name (Legal Business Name): JESSICA BARTRA CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 UNSER BLVD SE
RIO RANCHO NM
87124-4740
US

IV. Provider business mailing address

35 VISTA LARGA PL NE
RIO RANCHO NM
87124-4371
US

V. Phone/Fax

Practice location:
  • Phone: 505-253-7878
  • Fax:
Mailing address:
  • Phone: 505-702-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number57450
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: