Provider Demographics
NPI:1992194252
Name:KHALSA, GURUMITTAR K (DOM)
Entity Type:Individual
Prefix:
First Name:GURUMITTAR
Middle Name:K
Last Name:KHALSA
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 LLANO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2003
Mailing Address - Country:US
Mailing Address - Phone:505-982-6369
Mailing Address - Fax:
Practice Address - Street 1:1505 LLANO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2003
Practice Address - Country:US
Practice Address - Phone:505-690-0605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1160171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist