Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 61867 | NM |
NPI | 1003415753 |
---|---|
Provider Name | Jessica Wood |
First Address | Albuquerque, NM 87111-1038 |
Second Address | Los Lunas, NM 87031-4812 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2020 |
Last Update Date | 23/10/2020 |