Healthcare Provider Details

I. General information

NPI: 1083736136
Provider Name (Legal Business Name): WANICHA BURAPHACHEEP-COGGINS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 S PACHECO ST NM DOH FAMILY PLANNING PROGRAM
SANTA FE NM
87505-5472
US

IV. Provider business mailing address

2040 S PACHECO ST NM DOH FAMILY PLANNING PROGRAM
SANTA FE NM
87505-5472
US

V. Phone/Fax

Practice location:
  • Phone: 505-476-8870
  • Fax: 505-476-8898
Mailing address:
  • Phone: 505-476-8870
  • Fax: 505-476-8898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number98-34
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: