Provider Demographics
NPI:1134127772
Name:GOLDBLUM, KATE (NP)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:
Last Name:GOLDBLUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 MULBERRY NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106
Mailing Address - Country:US
Mailing Address - Phone:505-243-9739
Mailing Address - Fax:505-842-0650
Practice Address - Street 1:303 MULBERRY NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-243-9739
Practice Address - Fax:505-842-0650
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0293583-22363LF0000X
NMR11582207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28528042Medicaid
NM0293583-22OtherNURSE PRACTITIONER/ANCC