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General NPI Number Information
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NPI Number | 1174501191
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Entity Type | Individual
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Provider Name | SEAN FAHERTY MD
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Gender | Male
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Dates
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Enumeration Date | 01/09/2006
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Last Update Date | 08/20/2019
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Provider Practice Location Address
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Address Line | 2300 E 30TH ST BLDG B, STE 102
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City | FARMINGTON
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State | NM
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Zip | 87401-8990
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Country | US
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Telephone | 505-324-1000
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Fax | 505-324-1199
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Provider Business Mailing Address
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Address Line | 2300 E 30TH ST STE C2
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City | FARMINGTON
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State | NM
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Zip | 87401-8991
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Country | US
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Telephone | 505-324-1000
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Fax | 505-324-1199
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 98-47
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License Number State | NM
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