Provider Demographics
NPI:1891578340
Name:PETROGLYPH PRIMARY CARE AND CONSULTING LLC
Entity type:Organization
Organization Name:PETROGLYPH PRIMARY CARE AND CONSULTING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:ARCHULETA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, AGACNP-BC
Authorized Official - Phone:505-502-4401
Mailing Address - Street 1:6512 PATO RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-7007
Mailing Address - Country:US
Mailing Address - Phone:505-502-4401
Mailing Address - Fax:
Practice Address - Street 1:525 CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3221
Practice Address - Country:US
Practice Address - Phone:505-819-8434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-17
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM70802777Medicaid