Healthcare Provider Details

I. General information

NPI: 1114754223
Provider Name (Legal Business Name): PETER MAST CPSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2024
Last Update Date: 09/14/2024
Certification Date: 09/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DR STE 602
SANTA FE NM
87507-4929
US

IV. Provider business mailing address

4001 OFFICE COURT DR STE 602
SANTA FE NM
87507-4929
US

V. Phone/Fax

Practice location:
  • Phone: 505-207-8929
  • Fax:
Mailing address:
  • Phone: 505-207-8929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: