Healthcare Provider Details

I. General information

NPI: 1669270310
Provider Name (Legal Business Name): KIMBERLY FUSSELMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY SCOTT

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490A W ZIA RD
SANTA FE NM
87505-6996
US

IV. Provider business mailing address

2317 DIETZ FARM RD NW
ALBUQUERQUE NM
87107-3117
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-8900
  • Fax:
Mailing address:
  • Phone: 505-715-0008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2025-0024
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: