Provider Demographics
NPI:1245391556
Name:BLAIRE, PALOMA TERESE (DOM)
Entity type:Individual
Prefix:MS
First Name:PALOMA
Middle Name:TERESE
Last Name:BLAIRE
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:DR
Other - First Name:PALOMA
Other - Middle Name:TERESE
Other - Last Name:BLAIRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DOM
Mailing Address - Street 1:PO BOX 2901
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532
Mailing Address - Country:US
Mailing Address - Phone:505-747-7241
Mailing Address - Fax:505-747-7241
Practice Address - Street 1:1302 CALLE DE LA MERCED STE B
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2630
Practice Address - Country:US
Practice Address - Phone:505-747-7242
Practice Address - Fax:505-747-7242
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDOM240171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00R94SOtherBCBS
NM850477584OtherUNITED HEALTH CARE