Healthcare Provider Details

I. General information

NPI: 1821890385
Provider Name (Legal Business Name): DOMINIC WEILER FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7528 4TH ST NW STE A
LOS RANCHOS NM
87107-6683
US

IV. Provider business mailing address

7528 4TH ST NW STE A
LOS RANCHOS NM
87107-6683
US

V. Phone/Fax

Practice location:
  • Phone: 505-373-8068
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number56177
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: