Basic Information
| Provider Information | |||||||||
| NPI: | 1447890850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | NATALIE | ||||||||
| MiddleName: | RIOS | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 LOUISIANA BLVD NE STE 410 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871105412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057244300 | ||||||||
| FaxNumber: | 5057244384 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 LOUISIANA BLVD NE STE 410 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871105412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057244300 | ||||||||
| FaxNumber: | 5057244384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2020 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA2022-0082 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.