Healthcare Provider Details

I. General information

NPI: 1104141233
Provider Name (Legal Business Name): LAURA WAYMIRE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2010
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST STE B-102
FARMINGTON NM
87401-8991
US

IV. Provider business mailing address

PO BOX 844088
DALLAS TX
75284-4088
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6790
  • Fax: 505-599-4640
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD2014-0243
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: