Provider Demographics
NPI:1336543115
Name:PAMELA O BLACK MD, P.A., DBA QUADRA HEALTH INSTITUTE
Entity Type:Organization
Organization Name:PAMELA O BLACK MD, P.A., DBA QUADRA HEALTH INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD, P.A DBA QUADRA HEALTH INSTITUE
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:O
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-923-4401
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:
Mailing Address - Fax:
Practice Address - Street 1:3820 COMMONS AVE NE # M
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:505-923-4401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2014-0059363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty