Provider Demographics
NPI:1770854416
Name:GYPSUM MEDICAL ASSOCIATES OF NEW MEXICO, PC
Entity Type:Organization
Organization Name:GYPSUM MEDICAL ASSOCIATES OF NEW MEXICO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:MINGEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-363-9500
Mailing Address - Street 1:4805 PRIME PKWY
Mailing Address - Street 2:PO BOX 550
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-7002
Mailing Address - Country:US
Mailing Address - Phone:815-363-9500
Mailing Address - Fax:
Practice Address - Street 1:2501 BUENA VISTA DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4260
Practice Address - Country:US
Practice Address - Phone:505-923-5510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP01327363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty