Healthcare Provider Details

I. General information

NPI: 1902005572
Provider Name (Legal Business Name): NORTE VISTA MEDICAL ARTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 W TAOS ST
HOBBS NM
88240-1111
US

IV. Provider business mailing address

PO BOX 1798
HOBBS NM
88241-1798
US

V. Phone/Fax

Practice location:
  • Phone: 505-396-3529
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number86141
License Number StateNM

VIII. Authorized Official

Name: LENARD WAGNER
Title or Position: OWNER
Credential: M.D.
Phone: 505-396-3529