MEDICARE: MR. FERNANDO CARREON BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1821133042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FERNANDO CARREON BA

Provider Business Mailing Address
First Line	:	226 HERDNER RD
Second Line	:
City	:	TAOS
State	:	NM
Zip	:	87571-5213
Country	:	US
Telephone Number	:	505-751-1971
Fax Number	:

Provider Business Practice Location Address
First Line	:	413 SIPAPU
Second Line	:	BOX 6952
City	:	TAOS
State	:	NM
Zip	:	87571-6489
Country	:	US
Telephone Number	:	505-758-1596
Fax Number	:	505-758-2832

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	07/08/2007

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