Provider Demographics
NPI:1619980257
Name:NEW MEXICO VA HEALTHCARE SYSTEMS
Entity Type:Organization
Organization Name:NEW MEXICO VA HEALTHCARE SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SONTAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-265-1711
Mailing Address - Street 1:29 CHOLLA CREST DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9454
Mailing Address - Country:US
Mailing Address - Phone:505-286-8022
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-PA01286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital