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General NPI Number Information
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NPI Number | 1619237625
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Entity Type | Organization
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Legal Business Name | TADGE KANJO GENERAL SURGERY LLC
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Dates
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Enumeration Date | 05/23/2012
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Last Update Date | 04/30/2013
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Provider Practice Location Address
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Address Line | 196 ARROWHEAD DR SUITE 6
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City | EVANSTON
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State | WY
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Zip | 82930-8752
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Country | US
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Telephone | 307-783-8361
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Fax | 307-783-8399
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Provider Business Mailing Address
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Address Line | 196 ARROWHEAD DR SUITE 6
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City | EVANSTON
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State | WY
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Zip | 82930-8752
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Country | US
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Telephone | 307-783-8361
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Fax | 307-783-8399
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Authorized Official
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Title or Position | SOLE MBR
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Name | TADGE KANJO
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Credential | MD
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Telephone | 505-246-6910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MD2012-0060
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License Number State | NM
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