Healthcare Provider Details

I. General information

NPI: 1205892940
Provider Name (Legal Business Name): MARK GANAS RNCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 CARLISLE BLVD NE SUITE D
ALBUQUERQUE NM
87107-4829
US

IV. Provider business mailing address

4316 CARLISLE BLVD NE SUITE D
ALBUQUERQUE NM
87107-4829
US

V. Phone/Fax

Practice location:
  • Phone: 505-837-2100
  • Fax: 505-888-7943
Mailing address:
  • Phone: 505-837-2100
  • Fax: 505-888-7943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR25559
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: