Basic Information
| Provider Information | |||||||||
| NPI: | 1508950791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANAYA | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | SUITE 2222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | MSC10 5590 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722024 | ||||||||
| FaxNumber: | 5052722374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 93-192 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 054653302 | 05 | TX | MEDICAID | 162735 | 05 | AZ | MEDICAID | 0015964330001 | 05 | PA | MEDICAID | 0958074 | 05 | IA | MEDICAID | 1682900 | 05 | LA | MEDICAID | 208513101 | 05 | MO | MEDICAID | 6700322 | 05 | VA | MEDICAID | 06206 | 05 | NM | MEDICAID | 1-Z7176 | 05 | UT | MEDICAID | 203955 | 05 | OR | MEDICAID | XPY184605 | 05 | CA | MEDICAID | 91931923 | 05 | CO | MEDICAID |