Provider Demographics
NPI:1679884241
Name:REDISKE, NATHANIEL WEST (MD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:WEST
Last Name:REDISKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1509 VISTA LARGA CT NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2646
Mailing Address - Country:US
Mailing Address - Phone:414-403-6635
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:MSC11 6093
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-6225
Practice Address - Fax:505-272-5184
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT525862084P0800X
NMMD2015-06022084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry