Healthcare Provider Details

I. General information

NPI: 1609055102
Provider Name (Legal Business Name): NORTHERN NEW MEXICO PODIATRY ASSOC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 HARKLE RD
SANTA FE NM
87505-4751
US

IV. Provider business mailing address

665 HARKLE RD
SANTA FE NM
87505-4751
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-7393
  • Fax:
Mailing address:
  • Phone: 505-983-7393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number178
License Number StateNM

VIII. Authorized Official

Name: DR. JOEL M WILNER
Title or Position: PODIATRIST
Credential: DPM
Phone: 505-983-7393