Provider Demographics
NPI:1043610488
Name:ROTENBERG KOSHKIN, LEA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:LEA
Middle Name:
Last Name:ROTENBERG KOSHKIN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-262-3212
Mailing Address - Fax:505-232-1532
Practice Address - Street 1:5150 JOURNAL CENTER BLVD., NE
Practice Address - Street 2:ADULT INTERNAL MEDICINE - 3RD FLOOR
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-262-3212
Practice Address - Fax:505-232-1532
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMAPRN-CNP57838363L00000X
CA95001139363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner