Healthcare Provider Details

I. General information

NPI: 1457481871
Provider Name (Legal Business Name): MARY BUNKER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STATE HWY 518, MILE MARKER 29
MORA NM
87732-0185
US

IV. Provider business mailing address

PO BOX 185
MORA NM
87732-0185
US

V. Phone/Fax

Practice location:
  • Phone: 505-387-5503
  • Fax: 505-387-5502
Mailing address:
  • Phone: 505-387-5503
  • Fax: 505-387-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR11321
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: