Provider Demographics
NPI:1265873947
Name:SANGRA, PETER K (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:K
Last Name:SANGRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5045 MCNUTT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9442
Mailing Address - Country:US
Mailing Address - Phone:575-589-3000
Mailing Address - Fax:575-589-6682
Practice Address - Street 1:5055 MCNUTT RD
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9442
Practice Address - Country:US
Practice Address - Phone:575-589-3000
Practice Address - Fax:575-589-6682
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2017-09552084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry