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General NPI Number Information
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NPI Number | 1265405302
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Entity Type | Individual
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Provider Name | JAN A GOTTA M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/09/2006
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Last Update Date | 12/10/2009
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Provider Practice Location Address
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Address Line | 801 W MAPLE ST
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City | FARMINGTON
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State | NM
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Zip | 87401-5630
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Country | US
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Telephone | 505-326-6400
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Fax | 505-326-4606
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Provider Business Mailing Address
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Address Line | 1515 E 20TH ST SUITE A
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City | FARMINGTON
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State | NM
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Zip | 87401-9039
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Country | US
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Telephone | 505-326-6400
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Fax | 505-326-4606
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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 | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | MD2004-0691
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License Number State | NM
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