Healthcare Provider Details

I. General information

NPI: 1700608775
Provider Name (Legal Business Name): GUADALUPE S MATA CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 10/30/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 CAMINO DE VIDA STE 300
SANTA ROSA NM
88435-2267
US

IV. Provider business mailing address

117 CAMINO DE VIDA STE 300
SANTA ROSA NM
88435-2267
US

V. Phone/Fax

Practice location:
  • Phone: 575-472-4311
  • Fax: 877-651-0289
Mailing address:
  • Phone: 575-472-4311
  • Fax: 877-641-0289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-81461
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: