Healthcare Provider Details

I. General information

NPI: 1154493690
Provider Name (Legal Business Name): LISA S ROBLES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST STE A-3
SANTA FE NM
87505-2143
US

IV. Provider business mailing address

2019 GALISTEO ST STE A3
SANTA FE NM
87505-2143
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-2117
  • Fax: 505-988-2119
Mailing address:
  • Phone: 505-988-2117
  • Fax: 505-988-2119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberNM96-353
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: