Healthcare Provider Details

I. General information

NPI: 1003180423
Provider Name (Legal Business Name): AUDREY ANN BAUTISTA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NW METRO VA CLINIC 1760 GRANDE BLVD
RIO RANCHO NM
87124
US

IV. Provider business mailing address

NW METRO VA CLINIC 1760 GRANDE BLVD
RIO RANCHO NM
87124
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-7200
  • Fax: 505-994-4285
Mailing address:
  • Phone: 505-896-7200
  • Fax: 505-994-4285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-01570
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-01570
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: