Provider Demographics
NPI:1699881417
Name:NNM GASTROENTEROLOGY ASSOCIATES PA
Entity type:Organization
Organization Name:NNM GASTROENTEROLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-983-5631
Mailing Address - Street 1:1691 GALISTEO ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4780
Mailing Address - Country:US
Mailing Address - Phone:505-983-5631
Mailing Address - Fax:505-982-5605
Practice Address - Street 1:1691 GALISTEO ST
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4780
Practice Address - Country:US
Practice Address - Phone:505-983-5631
Practice Address - Fax:505-982-5605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM=========OtherTAX ID
NM=========Medicare PIN