Basic Information
| Provider Information | |||||||||
| NPI: | 1003123951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AUSTIN | ||||||||
| FirstName: | MIA | ||||||||
| MiddleName: | R. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 SAN PEDRO DR SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871085180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 SAN PEDRO DR SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871085180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2010 | ||||||||
| LastUpdateDate: | 03/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R48116 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.