Healthcare Provider Details

I. General information

NPI: 1225564800
Provider Name (Legal Business Name): MARIAM H BOKOLISHVILI S.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIAM BOKOLISHVILI M.D., S.A.

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 W ALAMEDA ST
SANTA FE NM
87501-1746
US

IV. Provider business mailing address

1511 W ALAMEDA ST
SANTA FE NM
87501-1746
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-3988
  • Fax:
Mailing address:
  • Phone: 505-459-3988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number15-489
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number15-489
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: