Healthcare Provider Details

I. General information

NPI: 1700328150
Provider Name (Legal Business Name): CHRISTOPHER JANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 LA JOYA ST STE D
ESPANOLA NM
87532-2877
US

IV. Provider business mailing address

706 LA JOYA ST STE D
ESPANOLA NM
87532-2877
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-6550
  • Fax: 505-753-1219
Mailing address:
  • Phone: 505-753-6550
  • Fax: 505-753-1219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0810
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: