Basic Information
| Provider Information | |||||||||
| NPI: | 1851485874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEBESTA | ||||||||
| FirstName: | EMILIE | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 UNIVERSITY BLVD NE | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052728950 | ||||||||
| FaxNumber: | 5052723202 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052728950 | ||||||||
| FaxNumber: | 5052723202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2004-0525 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 39308031 | 05 | NM | MEDICAID | 16855825 | 05 | CO | MEDICAID | 200081730 | 05 | OK | MEDICAID | 891160 | 05 | AZ | MEDICAID |