Healthcare Provider Details

I. General information

NPI: 1215375951
Provider Name (Legal Business Name): TIMOTHY MARK CANDELARIA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 HOSPITAL DR
SANTA FE NM
87505-4728
US

IV. Provider business mailing address

1631 HOSPITAL DR
SANTA FE NM
87505-4728
US

V. Phone/Fax

Practice location:
  • Phone: 505-323-7200
  • Fax: 505-323-7206
Mailing address:
  • Phone: 505-983-3275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR53366
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: