Basic Information
| Provider Information | |||||||||
| NPI: | 1821460734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERRIS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | BROSNAHAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROSNAHAN | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4420 IRVING BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871145915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057276300 | ||||||||
| FaxNumber: | 5057279588 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 IRVING BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871145915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057276300 | ||||||||
| FaxNumber: | 5057279588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2015 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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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 | 363A00000X | PA09488 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA60608545 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA2018-0015 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 82802548 | 05 | NM | MEDICAID |