Healthcare Provider Details

I. General information

NPI: 1477057164
Provider Name (Legal Business Name): AIMEE ZAGON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 HIGHWAY 14
SANTA FE NM
87508-1530
US

IV. Provider business mailing address

110 W LUPITA RD
SANTA FE NM
87505-4718
US

V. Phone/Fax

Practice location:
  • Phone: 505-827-8983
  • Fax:
Mailing address:
  • Phone: 505-984-3130
  • Fax: 505-984-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberPA-017
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: