Healthcare Provider Details

I. General information

NPI: 1477958973
Provider Name (Legal Business Name): NORTHERN NM GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 10/27/2014
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 Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberPA2014-0057
License Number StateNM

VIII. Authorized Official

Name: KAREN R CONNER
Title or Position: PA-C
Credential: PA-C
Phone: 505-983-5631