MEDICARE: MARK GANAS RNCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	R25559	NM

General Provider Information

NPI Number	:	1205892940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK GANAS RNCS

Provider Business Mailing Address
First Line	:	4316 CARLISLE BLVD NE
Second Line	:	SUITE D
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-4829
Country	:	US
Telephone Number	:	505-837-2100
Fax Number	:	505-888-7943

Provider Business Practice Location Address
First Line	:	4316 CARLISLE BLVD NE
Second Line	:	SUITE D
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87107-4829
Country	:	US
Telephone Number	:	505-837-2100
Fax Number	:	505-888-7943

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	07/08/2007

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