Provider Demographics
NPI:1760662548
Name:SWAN, WILLIAM STACEY (ABO)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:STACEY
Last Name:SWAN
Suffix:
Gender:M
Credentials:ABO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S PLAZA
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-5957
Mailing Address - Country:US
Mailing Address - Phone:575-751-1565
Mailing Address - Fax:575-751-1907
Practice Address - Street 1:104 S PLAZA
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5957
Practice Address - Country:US
Practice Address - Phone:575-751-1565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician