Basic Information
| Provider Information | |||||||||
| NPI: | 1326326794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CZECH-SIEWERT | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | |||||||||
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| Credential: | ANP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PHS PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8300 CONSTITUTION AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052912356 | ||||||||
| FaxNumber: | 5052912656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2011 | ||||||||
| LastUpdateDate: | 09/03/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | AP4000 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 005234 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | CNP-02478 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 630566 | 05 | AZ | MEDICAID |