Organization
VISTA EMERGENCY PHYSICIANS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KATHY KONDAS (OFFICER)
(973) 251-1132
Entity
Organization
Contact information
Practice address
1015 E ROOSEVELT AVE, EMERGENCY DEPARTMENT, GRANTS, NM 87020-2117
(973) 251-1132
Mailing address
13737 NOEL RD, STE 1600, DALLAS, TX 75240-1331
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
28477073
—
NM
01
—
NM007D60
BLUE SHIELD OF NEW MEXICO
NM
Enumeration date
05/10/2006
Last updated
12/05/2019
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