Provider Demographics
NPI:1811921943
Name:COLTON, MARY MAGDALENA (CNM)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MAGDALENA
Last Name:COLTON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:MAGDALENA
Other - Last Name:WEINER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:516 E. NIZHONI BLVD.
Mailing Address - Street 2:BOX 1337
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1268
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:BOX 1337
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1268
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR44205163W00000X
NM444367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Z4706Medicaid
AZ810532Medicaid
S83493Medicare UPIN
TX8HBP09Medicare ID - Type UnspecifiedHSZ006