Provider Demographics
NPI:1558568162
Name:GOULET, KRISTIAN BERNARD (MB, BCH, BAO)
Entity type:Individual
Prefix:DR
First Name:KRISTIAN
Middle Name:BERNARD
Last Name:GOULET
Suffix:
Gender:M
Credentials:MB, BCH, BAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6533 MESA MARIPOSA PL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3364
Mailing Address - Country:US
Mailing Address - Phone:505-856-2166
Mailing Address - Fax:
Practice Address - Street 1:MSC 08
Practice Address - Street 2:1 UNIVERSITY OF NEW MEXICO
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-6225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRS20070321208000000X
MA243449208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMRS20070321OtherSTATE LICENCE NUMBER