Provider Demographics
NPI:1083305510
Name:MAYEDEL A. SAN JOSE PC
Entity Type:Organization
Organization Name:MAYEDEL A. SAN JOSE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYEDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SAN JOSE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-C
Authorized Official - Phone:575-332-4633
Mailing Address - Street 1:1245 COUNTRY CLUB RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9743
Mailing Address - Country:US
Mailing Address - Phone:575-332-4633
Mailing Address - Fax:877-209-8941
Practice Address - Street 1:1245 COUNTRY CLUB RD STE 200
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9743
Practice Address - Country:US
Practice Address - Phone:575-332-4633
Practice Address - Fax:877-209-8941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service