Healthcare Provider Details

I. General information

NPI: 1538320437
Provider Name (Legal Business Name): KYLE WESLEY SANDERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MAPLE ST
FARMINGTON NM
87401-5630
US

IV. Provider business mailing address

PO BOX 2019
FARMINGTON NM
87499-2019
US

V. Phone/Fax

Practice location:
  • Phone: 56-096-2285
  • Fax:
Mailing address:
  • Phone: 505-325-1572
  • Fax: 505-327-4887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number069136
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number69136
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number9532955-1205
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberE-9650
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number55072-020
License Number StateWI
# 6
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036.140664
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2016009166
License Number StateMO
# 8
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2017-0879
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: