1376574079 NPI number — MARY E HARRISON

Table of content: MARY E HARRISON (NPI 1376574079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376574079 NPI number — MARY E HARRISON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRISON
Provider First Name:
MARY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1376574079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 RODEO LN
Provider Second Line Business Mailing Address:
STE A-1
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87507-6400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-216-3615
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 PASEO DEL PUEBLO SUR
Provider Second Line Business Practice Location Address:
UNIT C
Provider Business Practice Location Address City Name:
TAOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87571-5219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-758-1414
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2006

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: 363LF0000X , with the licence number:  CNP00253 , 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: 74867 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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