Provider Demographics
NPI:1720351869
Name:GREGG FLAX, PAMELA JEAN (DOM)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:GREGG FLAX
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 1:4751 AGUA FRIA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-9251
Mailing Address - Country:US
Mailing Address - Phone:505-690-8048
Mailing Address - Fax:
Practice Address - Street 1:1300 LUISA ST STE 21
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4177
Practice Address - Country:US
Practice Address - Phone:505-690-8048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1072171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist