Healthcare Provider Details

I. General information

NPI: 1679614622
Provider Name (Legal Business Name): NAOMI J KISTIN MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 STANFORD DR NE
ALBUQUERQUE NM
87106-3721
US

IV. Provider business mailing address

1111 STANFORD DR NE
ALBUQUERQUE NM
87106-3721
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-4113
  • Fax: 505-841-4147
Mailing address:
  • Phone: 505-841-4113
  • Fax: 505-841-4147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number95-90
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: