Basic Information
| Provider Information | |||||||||
| NPI: | 1205935004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SELVAGE | ||||||||
| FirstName: | TERESE | ||||||||
| MiddleName: | AILEEN O'NEIL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MN, CNP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | O'NEIL | ||||||||
| OtherFirstName: | TERESE | ||||||||
| OtherMiddleName: | AILEEN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MN, CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2720 CALLE CEDRO | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875055297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054710715 | ||||||||
| FaxNumber: | 5059846918 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 W ALAMEDA ST STE 25 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875011673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059888869 | ||||||||
| FaxNumber: | 5059826298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CNP00790 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LA2200X | R36675 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.