Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 1375 | NM |
NPI | 1093720864 |
---|---|
Provider Name | Dr. Bruce Wayne Klinekole |
First Address | Ruidoso, NM 88345-6950 |
Second Address | Ruidoso, NM 88345-6950 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
51562 | HMO NEW MEXICO (01) | NM |
KC53 | BLUE CROSS BLUE SHIELD (01) | NM |
L4208 | (05) | NM |
U62363 | (02) | NM |