Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 78-226 | NM |
NPI | 1063419547 |
---|---|
Provider Name | Henry Huson Middleton III |
First Address | Albuquerque, NM 87112-4160 |
Second Address | Albuquerque, NM 87113-1757 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2005 |
Last Update Date | 21/08/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
06064 | (05) | NM |
E09296 | (02) | NM |