Healthcare Provider Details

I. General information

NPI: 1790045839
Provider Name (Legal Business Name): JOAN BAUMBACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 S SAINT FRANCIS DR N1350
SANTA FE NM
87505-4173
US

IV. Provider business mailing address

1190 S SAINT FRANCIS DR N1350
SANTA FE NM
87505-4173
US

V. Phone/Fax

Practice location:
  • Phone: 505-827-0011
  • Fax: 505-827-0013
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number96-191
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: