Healthcare Provider Details

I. General information

NPI: 1326777418
Provider Name (Legal Business Name): MOUNTAIN SAGE MEDICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 OLD PECOS TRL STE F
SANTA FE NM
87505-4768
US

IV. Provider business mailing address

1660 OLD PECOS TRL STE F
SANTA FE NM
87505-4768
US

V. Phone/Fax

Practice location:
  • Phone: 505-472-7243
  • Fax: 505-472-7244
Mailing address:
  • Phone: 505-472-7243
  • Fax: 505-472-7244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SUSAN BARRETT
Title or Position: OWNER
Credential: APRN-CNP
Phone: 505-472-7243