Provider Demographics
NPI:1528526464
Name:DHARMARAJAN, ILANGO (AGPCNP-BC)
Entity type:Individual
Prefix:MR
First Name:ILANGO
Middle Name:
Last Name:DHARMARAJAN
Suffix:
Gender:M
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 SAINT MICHAELS DR STE 230
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-8602
Mailing Address - Country:US
Mailing Address - Phone:505-913-4710
Mailing Address - Fax:505-913-4711
Practice Address - Street 1:465 SAINT MICHAELS DR STE 116
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7621
Practice Address - Country:US
Practice Address - Phone:505-984-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2022-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM55465363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology