Healthcare Provider Details

I. General information

NPI: 1699881417
Provider Name (Legal Business Name): NNM GASTROENTEROLOGY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 GALISTEO ST SUITE C
SANTA FE NM
87505-4780
US

IV. Provider business mailing address

1691 GALISTEO ST SUITE C
SANTA FE NM
87505-4780
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-5631
  • Fax: 505-982-5605
Mailing address:
  • Phone: 505-983-5631
  • Fax: 505-982-5605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: LISA MENDIOLA
Title or Position: ADMINISTRATIVE ASST
Credential:
Phone: 505-983-5631