Healthcare Provider Details

I. General information

NPI: 1891790192
Provider Name (Legal Business Name): LAWRENCE G WAYBURN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 BIG BEAR PL
SANTA FE NM
87508
US

IV. Provider business mailing address

2 BIG BEAR PL
SANTA FE NM
87508
US

V. Phone/Fax

Practice location:
  • Phone: 989-928-2397
  • Fax: 505-471-4388
Mailing address:
  • Phone: 989-928-2397
  • Fax: 505-471-4388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2007-0243
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: