Basic Information
| Provider Information | |||||||||
| NPI: | 1952533952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WUBBENHORST | ||||||||
| FirstName: | TERRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | MSC 10-6000 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | MSC 10-6000 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722610 | ||||||||
| FaxNumber: | 5052721300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2009 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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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 | 207L00000X | P9036 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | MD2018-0687 | NM | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 332344603 | 05 | TX | MEDICAID | 332344604 | 05 | TX | MEDICAID | 8FN269 | 01 | TX | BCBS | OTHER |