Provider Demographics
NPI:1629030390
Name:BLACK, PAMELA O (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:O
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 25206
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-0206
Mailing Address - Country:US
Mailing Address - Phone:505-343-1711
Mailing Address - Fax:505-343-1862
Practice Address - Street 1:3820 COMMONS AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5831
Practice Address - Country:US
Practice Address - Phone:505-343-1711
Practice Address - Fax:505-343-1862
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM97-192208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
347303801Medicare PIN
E93885Medicare UPIN