Provider Demographics
NPI:1265476550
Name:NICOLETTE, LINDA A (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:A
Last Name:NICOLETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:DECKLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:201 CEDAR ST SE STE 4660
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4924
Practice Address - Country:US
Practice Address - Phone:505-563-6530
Practice Address - Fax:505-563-6336
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204554208600000X, 2086S0120X
NM91-1012086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01690293Medicaid
NM56509766Medicaid
NY01690293Medicaid
NM56509766Medicaid
NMNM303016Medicare PIN