Basic Information
| Provider Information | |||||||||
| NPI: | 1619980257 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW MEXICO VA HEALTHCARE SYSTEMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 CHOLLA CREST DR | ||||||||
| Address2: | |||||||||
| City: | CEDAR CREST | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870089454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052868022 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 SAN PEDRO DR SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871085153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 07/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | SONTAG | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 5052651711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | 91-PA01 | NM | Y | Hospitals | Military Hospital |
No ID Information.