Healthcare Provider Details

I. General information

NPI: 1770528085
Provider Name (Legal Business Name): WALTER FARR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 PLAZA BLANCA
SANTA FE NM
87507-5340
US

IV. Provider business mailing address

2940 PLAZA BLANCA
SANTA FE NM
87507-5340
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-4448
  • Fax:
Mailing address:
  • Phone: 505-438-4448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2003-0536
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: