MEDICARE: MS. BOSHA A GORDON APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	CNP00393	NM

General Provider Information

NPI Number	:	1114055365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BOSHA A GORDON APRN

Provider Business Mailing Address
First Line	:	2829 INDIANA ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-3427
Country	:	US
Telephone Number	:	505-508-1304
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 MEDICAL ARTS AVE NE # UNM
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87102-2708
Country	:	US
Telephone Number	:	505-272-5132
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	05/22/2011

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