Healthcare Provider Details

I. General information

NPI: 1316050560
Provider Name (Legal Business Name): ALYSON P THAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3841 CORRALES RD
CORRALES NM
87048-9311
US

IV. Provider business mailing address

PO BOX 2090 3841 CORRALES ROAD
CORRALES NM
87048-2090
US

V. Phone/Fax

Practice location:
  • Phone: 505-792-3065
  • Fax: 505-792-4004
Mailing address:
  • Phone: 505-792-3065
  • Fax: 505-792-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number86-346
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: