Healthcare Provider Details

I. General information

NPI: 1073563326
Provider Name (Legal Business Name): CHARLES T WEMPLE R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 SIPAPU ST
TAOS NM
87571-6489
US

IV. Provider business mailing address

PO BOX 1403
EL PRADO NM
87529-1403
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-5857
  • Fax: 575-758-2832
Mailing address:
  • Phone: 575-613-2098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-75869
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: