Healthcare Provider Details

I. General information

NPI: 1164607982
Provider Name (Legal Business Name): WELMAN AUSTIN SHRADER JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 12/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 PASEO DE PERALTA
SANTA FE NM
87501-2914
US

IV. Provider business mailing address

141 PASEO DE PERALTA
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-8890
  • Fax:
Mailing address:
  • Phone: 505-983-8890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number91-308
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: