Healthcare Provider Details

I. General information

NPI: 1861693137
Provider Name (Legal Business Name): NATHAN A WALES DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 OLD PECOS TRL SUITE H
SANTA FE NM
87505-4779
US

IV. Provider business mailing address

2370 CAMINO MELITON APT A
SANTA FE NM
87507
US

V. Phone/Fax

Practice location:
  • Phone: 505-470-5705
  • Fax:
Mailing address:
  • Phone: 505-470-5705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number926
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: