Healthcare Provider Details

I. General information

NPI: 1457382160
Provider Name (Legal Business Name): DAVID A RASKIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1399 WEIMER RAOD SUITE 200
TAOS NM
87571
US

IV. Provider business mailing address

1397 WEIMER RD
TAOS NM
87571-6284
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-2224
  • Fax:
Mailing address:
  • Phone: 505-758-2224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR11351
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: