Provider Demographics
NPI:1477958973
Name:NORTHERN NM GASTROENTEROLOGY
Entity Type:Organization
Organization Name:NORTHERN NM GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:505-983-5631
Mailing Address - Street 1:1691 GALISTEO ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4780
Mailing Address - Country:US
Mailing Address - Phone:505-983-5631
Mailing Address - Fax:505-982-5605
Practice Address - Street 1:1691 GALISTEO ST
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4780
Practice Address - Country:US
Practice Address - Phone:505-983-5631
Practice Address - Fax:505-982-5605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2014-0057261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty