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General NPI Number Information
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NPI Number | 1578388633
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Entity Type | Individual
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Provider Name | KYLE DEISIG FNP-C
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Gender | Male
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Dates
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Enumeration Date | 11/22/2024
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Last Update Date | 12/05/2024
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Provider Practice Location Address
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Address Line | PO BOX 133
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City | ANGEL FIRE
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State | NM
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Zip | 87710-0133
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Country | US
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Telephone | 575-377-3301
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Fax |
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Provider Business Mailing Address
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Address Line | 41 LAGUNA RD
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City | EAGLE NEST
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State | NM
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Zip | 87718-9003
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Country | US
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Telephone |
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Fax |
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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 | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 66201
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 66201
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License Number State | NM
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