Basic Information
| Provider Information | |||||||||
| NPI: | 1346285095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAXTER | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6701 JEFFERSON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057270600 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Practice Location | |||||||||
| Address1: | 6701 JEFFERSON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057270600 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | CNP01179 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | CNP01179 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 80503811 | 05 | NM | MEDICAID | A031 | 01 | NM | TRICARE | OTHER |