Healthcare Provider Details

I. General information

NPI: 1295930881
Provider Name (Legal Business Name): CHAYANIN MUSIKASINTHORN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 EAST NIZHONI BLVD.
GALLUP NM
87301-1337
US

IV. Provider business mailing address

P.O. BOX 1337
GALLUP NM
87305-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1650
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMDR5069
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD14862
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: