Healthcare Provider Details

I. General information

NPI: 1417915141
Provider Name (Legal Business Name): YVONNE JANICE CORCORAN D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 JUAN TABO BLVD NE SUITE 7
ALBUQUERQUE NM
87111-3992
US

IV. Provider business mailing address

3909 JUAN TABO BLVD NE SUITE 7
ALBUQUERQUE NM
87111-3992
US

V. Phone/Fax

Practice location:
  • Phone: 505-288-2215
  • Fax:
Mailing address:
  • Phone: 505-288-2215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number821
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: