Healthcare Provider Details

I. General information

NPI: 1972562478
Provider Name (Legal Business Name): GILLIAN ELECTA MAIR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

PO BOX 1337
GALLUP NM
87305-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1268
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35061091M
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: