Healthcare Provider Details

I. General information

NPI: 1790784973
Provider Name (Legal Business Name): DIANNA LYNNE FURY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 SANDIA DAY SCHOOL ROAD
BERNALILLO NM
87004
US

IV. Provider business mailing address

481 SANDIA LOOP
BERNALILLO NM
87004-7076
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-4696
  • Fax: 505-867-4997
Mailing address:
  • Phone: 505-867-4696
  • Fax: 505-867-4997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30414
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2011-0163
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: