Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | DC2205 | NM |
NPI | 1174080527 |
---|---|
Provider Name | Amanda Smith |
First Address | Albuquerque, NM 87111-3857 |
Second Address | Albuquerque, NM 87111-3857 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/02/2019 |
Last Update Date | 21/02/2019 |