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General NPI Number Information
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NPI Number | 1326777418
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Entity Type | Organization
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Legal Business Name | MOUNTAIN SAGE MEDICO
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Dates
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Enumeration Date | 06/06/2022
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Last Update Date | 09/29/2023
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Provider Practice Location Address
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Address Line | 1660 OLD PECOS TRL STE F
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City | SANTA FE
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State | NM
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Zip | 87505-4768
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Country | US
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Telephone | 505-472-7243
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Fax | 505-472-7244
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Provider Business Mailing Address
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Address Line | 1660 OLD PECOS TRL STE F
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City | SANTA FE
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State | NM
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Zip | 87505-4768
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Country | US
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Telephone | 505-472-7243
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Fax | 505-472-7244
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Authorized Official
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Title or Position | OWNER
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Name | SUSAN BARRETT
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Credential | APRN-CNP
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Telephone | 505-472-7243
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number |
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License Number State |
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