Provider Demographics
NPI:1790959203
Name:PENDERGRASS, STEPHANIE HUE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:HUE
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:JANE
Other - Last Name:HUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11120 MALAGUENA LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6861
Mailing Address - Country:US
Mailing Address - Phone:505-401-8956
Mailing Address - Fax:
Practice Address - Street 1:11120 MALAGUENA LN NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-6861
Practice Address - Country:US
Practice Address - Phone:505-401-8956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0832208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics