Healthcare Provider Details

I. General information

NPI: 1831330364
Provider Name (Legal Business Name): FAMILY MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 NIZHONI BLVD
GALLUP NM
87301-5757
US

IV. Provider business mailing address

517 NIZHONI BLVD
GALLUP NM
87301-5757
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-6603
  • Fax: 505-722-6111
Mailing address:
  • Phone: 505-722-6603
  • Fax: 505-722-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2003-0154
License Number StateNM

VIII. Authorized Official

Name: MRS. SUSIE FRONTEROTTA
Title or Position: MANAGER
Credential:
Phone: 505-722-6603