Facts
- Status
- A
- Credential
- MD
- Type
- Individual
- Enumeration date
- 2006-09-28
- Last updated
- 2015-10-22
Licenses
- License UT
- 9114209-1205
- License NM
- MD2007-0220
Location
- Practice location
- 4565 RANCH BLVD
- City
- MORGAN UT
- Postal code
- 840505515
- Phone
- 505-434-3137
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.