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General NPI Number Information
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NPI Number | 1770854416
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Entity Type | Organization
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Legal Business Name | GYPSUM MEDICAL ASSOCIATES OF NEW MEXICO, PC
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Dates
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Enumeration Date | 01/25/2012
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Last Update Date | 01/25/2012
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Provider Practice Location Address
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Address Line | 2501 BUENA VISTA DR SE
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City | ALBUQUERQUE
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State | NM
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Zip | 87106-4260
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Country | US
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Telephone | 505-923-5510
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Fax |
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Provider Business Mailing Address
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Address Line | 4805 PRIME PKWY PO BOX 550
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City | MCHENRY
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State | IL
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Zip | 60050-7002
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Country | US
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Telephone | 815-363-9500
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. GEORGE DANIEL MINGEA
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Credential |
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Telephone | 815-363-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | CNP01327
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License Number State | NM
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