Healthcare Provider Details

I. General information

NPI: 1780339457
Provider Name (Legal Business Name): CHIP UPSAL RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 SAINT MICHAELS DR
SANTA FE NM
87505-7602
US

IV. Provider business mailing address

2608 ALAMOSA DR
SANTA FE NM
87505-5216
US

V. Phone/Fax

Practice location:
  • Phone: 505-303-5000
  • Fax: 505-303-5199
Mailing address:
  • Phone: 505-577-6596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR67343
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: