Provider Demographics
NPI:1235789157
Name:OBERMULLER, PATRICK O
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:O
Last Name:OBERMULLER
Suffix:
Gender:M
Credentials:
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 44971
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-4971
Mailing Address - Country:US
Mailing Address - Phone:575-415-8575
Mailing Address - Fax:
Practice Address - Street 1:4101 MOUNTAIN TRAIL LOOP NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-7012
Practice Address - Country:US
Practice Address - Phone:575-415-8575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCAD0200771101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16062019Medicaid