Healthcare Provider Details

I. General information

NPI: 1013630755
Provider Name (Legal Business Name): MARK WOODWARD NREMT-BASIC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2052 GALISTEO ST
SANTA FE NM
87505-2100
US

IV. Provider business mailing address

2052 GALISTEO ST
SANTA FE NM
87505-2100
US

V. Phone/Fax

Practice location:
  • Phone: 505-819-3419
  • Fax:
Mailing address:
  • Phone: 505-819-3419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberE3672633
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: