Basic Information
| Provider Information | |||||||||
| NPI: | 1376545418 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOLTENSMEYER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 LOUISIANA BLVD NE | ||||||||
| Address2: | STE 401 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052604300 | ||||||||
| FaxNumber: | 5052604338 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 SUDDERTH DR | ||||||||
| Address2: | |||||||||
| City: | RUIDOSO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 883456002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052577381 | ||||||||
| FaxNumber: | 5052604338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R16486 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | NM006219 | 01 | NM | BLUE CROSS BLUE SHIELD | OTHER | 59147 | 05 | NM | MEDICAID | 22267 | 05 | NM | MEDICAID | 750192 | 05 | AZ | MEDICAID |