Provider Demographics
NPI:1811008717
Name:ARCHULETA, KIMBERLY (CNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ARCHULETA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:PMG SAN MATEO
Practice Address - Street 2:401 SAN MATEO BLVD SE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-462-7333
Practice Address - Fax:505-462-7495
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR43799207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37289578Medicaid
343634302Medicare PIN
NM37289578Medicaid