Healthcare Provider Details

I. General information

NPI: 1114996188
Provider Name (Legal Business Name): ISIS MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 BOTULPH LN
SANTA FE NM
87505-6912
US

IV. Provider business mailing address

401 BOTULPH LN
SANTA FE NM
87505-6912
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-8387
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2005-0046
License Number StateNM

VIII. Authorized Official

Name: ANNA ANNON
Title or Position: ADMINISTRTIVE ASSISTANT
Credential:
Phone: 505-983-8387