Healthcare Provider Details

I. General information

NPI: 1205693579
Provider Name (Legal Business Name): CHRISTOPHER CODY BALDONADO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

IV. Provider business mailing address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

V. Phone/Fax

Practice location:
  • Phone: 505-397-5797
  • Fax: 877-396-1184
Mailing address:
  • Phone: 505-397-5797
  • Fax: 877-396-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberRN-84782
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: