Healthcare Provider Details

I. General information

NPI: 1023482585
Provider Name (Legal Business Name): MIN BAE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2015
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 BATAAN MEMORIAL E # LC
LAS CRUCES NM
88011-6011
US

IV. Provider business mailing address

2175 SEDONA HILLS PKWY
LAS CRUCES NM
88011-4135
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-8603
  • Fax:
Mailing address:
  • Phone: 217-390-4513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007969
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: