Basic Information
| Provider Information | |||||||||
| NPI: | 1629030390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25206 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871250206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053431711 | ||||||||
| FaxNumber: | 5053431862 | ||||||||
| Practice Location | |||||||||
| Address1: | 3820 COMMONS AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871095831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053431711 | ||||||||
| FaxNumber: | 5053431862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 12/13/2013 | ||||||||
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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 | 208100000X | 97-192 | NM | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.