Healthcare Provider Details

I. General information

NPI: 1699272633
Provider Name (Legal Business Name): WALTER BARNEY SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 LUNA VIS
SANTA FE NM
87506-2003
US

IV. Provider business mailing address

708 LUNA VIS
SANTA FE NM
87506-2003
US

V. Phone/Fax

Practice location:
  • Phone: 505-850-7953
  • Fax: 505-983-8724
Mailing address:
  • Phone: 505-850-7953
  • Fax: 505-983-8724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: