Healthcare Provider Details

I. General information

NPI: 1922376896
Provider Name (Legal Business Name): ANGEL FIRE PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 ASPEN
ANGEL FIRE NM
87710-0000
US

IV. Provider business mailing address

707 PASEO DE PERALTA
SANTA FE NM
87501-1922
US

V. Phone/Fax

Practice location:
  • Phone: 575-377-1805
  • Fax:
Mailing address:
  • Phone: 505-989-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNM

VIII. Authorized Official

Name: DR. LESA D FRAKER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-989-8707