1790784973 NPI number — DR. DIANNA LYNNE FURY MD

Table of content: DR. DIANNA LYNNE FURY MD (NPI 1790784973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790784973 NPI number — DR. DIANNA LYNNE FURY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FURY
Provider First Name:
DIANNA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790784973
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
481 SANDIA LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERNALILLO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87004-7076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-867-4696
Provider Business Mailing Address Fax Number:
505-867-4997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 SANDIA DAY SCHOOL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERNALILLO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-867-4696
Provider Business Practice Location Address Fax Number:
505-867-4997
Provider Enumeration Date:
07/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  30414 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD2011-0163 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07235551 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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