Provider Demographics
NPI:1790045839
Name:BAUMBACH, JOAN
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:BAUMBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 S SAINT FRANCIS DR
Mailing Address - Street 2:N1350
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1190 S SAINT FRANCIS DR
Practice Address - Street 2:N1350
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4173
Practice Address - Country:US
Practice Address - Phone:505-827-0011
Practice Address - Fax:505-827-0013
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96-191208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice