Provider Demographics
NPI:1831723899
Name:ZUNI, RANDALL (CPSW,BSN)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:ZUNI
Suffix:
Gender:M
Credentials:CPSW,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 VANDENBOSCH PKWY
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5508
Mailing Address - Country:US
Mailing Address - Phone:505-726-6919
Mailing Address - Fax:505-726-6937
Practice Address - Street 1:650 VANDENBOSCH PKWY
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5508
Practice Address - Country:US
Practice Address - Phone:505-726-6919
Practice Address - Fax:505-726-6937
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1050171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1050OtherCERTIFIED PEER SUPPORT WORKER