Healthcare Provider Details

I. General information

NPI: 1891915542
Provider Name (Legal Business Name): JONATHAN ANDREW TRAPP DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2074 GALISTEO ST SUITE A-4
SANTA FE NM
87505-2138
US

IV. Provider business mailing address

815 GILDERSLEEVE ST
SANTA FE NM
87505-2637
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-0679
  • Fax:
Mailing address:
  • Phone: 505-982-0679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number384
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: