Provider Demographics
NPI:1811241896
Name:WHITEHORSE, SURRINA
Entity type:Individual
Prefix:
First Name:SURRINA
Middle Name:
Last Name:WHITEHORSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1343
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87417-1343
Mailing Address - Country:US
Mailing Address - Phone:505-419-3279
Mailing Address - Fax:
Practice Address - Street 1:HWY 160 MM 284: 8 MILES
Practice Address - Street 2:
Practice Address - City:TEECNOSPOS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:505-419-3279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM033435380343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)