Healthcare Provider Details

I. General information

NPI: 1861417453
Provider Name (Legal Business Name): ROBERT JOHN BENON MSN, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 YUCCA ST STUDENT SERVICES BLDG.
SANTA FE NM
87505-5456
US

IV. Provider business mailing address

1880A CALLE QUEDO
SANTA FE NM
87505-5433
US

V. Phone/Fax

Practice location:
  • Phone: 505-467-2439
  • Fax: 505-467-2989
Mailing address:
  • Phone: 505-438-9139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR21020
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: