1730514977 NPI number — DR. YVONNE WYLIE WALSTON D.O.M.

Table of content: DR. YVONNE WYLIE WALSTON D.O.M. (NPI 1730514977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730514977 NPI number — DR. YVONNE WYLIE WALSTON D.O.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALSTON
Provider First Name:
YVONNE
Provider Middle Name:
WYLIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.M.
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:
1730514977
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2817 ESPANOLA ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87110-3522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-604-5593
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 LOUISIANA BLVD NE
Provider Second Line Business Practice Location Address:
NORTH BLDG STE B3
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87110-3532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-604-5593
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2013

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: 171100000X , with the licence number:  1114 , 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)





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