Provider Demographics
NPI:1255425633
Name:HIDALGO, THERESE (CFNP)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:HIDALGO
Suffix:
Gender:F
Credentials:CFNP
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 1:1619 W. DELGADO
Practice Address - Street 2:BELEN HIGH SCHOOL-BASED HEALTH CENTER
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002
Practice Address - Country:US
Practice Address - Phone:505-966-1381
Practice Address - Fax:505-966-1385
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR18189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000L6495Medicaid
NM000L6495Medicaid
R74109Medicare UPIN