Healthcare Provider Details

I. General information

NPI: 1194740167
Provider Name (Legal Business Name): ROBERT JOHN WALANTAS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 10/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST STE J1
SANTA FE NM
87505-2103
US

IV. Provider business mailing address

2019 GALISTEO ST STE J1
SANTA FE NM
87505-2103
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-0446
  • Fax: 505-820-6142
Mailing address:
  • Phone: 505-820-0446
  • Fax: 505-820-6142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number500800
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP00794
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: