Healthcare Provider Details

I. General information

NPI: 1437356474
Provider Name (Legal Business Name): ROBERT WISNEWSKI DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E HILL AVE GALLUP
GALLUP NM
87301-6257
US

IV. Provider business mailing address

3415 SILVER AVE SE
ALBUQUERQUE NM
87106-1438
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-8018
  • Fax:
Mailing address:
  • Phone: 505-265-5087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number939
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: