Provider Demographics
NPI:1023293990
Name:COREY SUTTER FNP
Entity type:Organization
Organization Name:COREY SUTTER FNP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MS
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:505-820-0446
Mailing Address - Street 1:2019 GALISTEO ST
Mailing Address - Street 2:STE J-1
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2143
Mailing Address - Country:US
Mailing Address - Phone:505-820-0446
Mailing Address - Fax:505-820-6142
Practice Address - Street 1:2019 GALISTEO ST
Practice Address - Street 2:STE J-1
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2143
Practice Address - Country:US
Practice Address - Phone:505-820-0446
Practice Address - Fax:505-820-6142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR29804363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000R9598Medicaid
NM100521088Medicare PIN
NM000R9598Medicaid