Provider Demographics
NPI:1467457648
Name:CARBAJO, PATRICIA WILSON (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:WILSON
Last Name:CARBAJO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 W HOUGHTON ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-8849
Mailing Address - Country:US
Mailing Address - Phone:505-577-8282
Mailing Address - Fax:505-843-2931
Practice Address - Street 1:504 ELM ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2512
Practice Address - Country:US
Practice Address - Phone:505-724-2005
Practice Address - Fax:505-843-2931
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2000-154207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68282Medicaid
NM341431004Medicare ID - Type UnspecifiedNM MEDICARE #
NM68282Medicaid