Healthcare Provider Details

I. General information

NPI: 1518902055
Provider Name (Legal Business Name): CHAD HOUGHTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 06/07/2018
Certification Date:
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 6210
FARMINGTON NM
87499-6210
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-6400
  • Fax: 505-326-4606
Mailing address:
  • Phone: 505-326-6400
  • Fax: 505-326-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR41412
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: