Provider Demographics
NPI:1891753836
Name:WARREN, ELLEN RHEA (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:RHEA
Last Name:WARREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PASEO DEL PUEBLO SUR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6070
Mailing Address - Country:US
Mailing Address - Phone:575-758-3005
Mailing Address - Fax:575-758-7010
Practice Address - Street 1:630 PASEO DEL PUEBLO SUR
Practice Address - Street 2:SUITE 150
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6070
Practice Address - Country:US
Practice Address - Phone:575-758-3005
Practice Address - Fax:575-758-7010
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-09-22
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-03
Provider Licenses
StateLicense IDTaxonomies
NM82-332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09167Medicaid
080098206OtherRAILROAD MEDICARE
D36019Medicare UPIN
NM2133083Medicare PIN