Basic Information
| Provider Information | |||||||||
| NPI: | 1992864896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PINO | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CEDAR ST SE | ||||||||
| Address2: | STE. 5640 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058436168 | ||||||||
| FaxNumber: | 5052479743 | ||||||||
| Practice Location | |||||||||
| Address1: | 80B VETERANS BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525415 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 02/13/2015 | ||||||||
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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 | 176B00000X | 472 | NM | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | F6124 | 05 | NM | MEDICAID |