Healthcare Provider Details

I. General information

NPI: 1427064179
Provider Name (Legal Business Name): GAYLE CHACON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 SANDIA LOOP SANDIA PUEBLO CLINIC
BERNALILLO NM
87004-7076
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-4487
  • Fax:
Mailing address:
  • Phone: 505-272-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number96-28
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: