Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | A-1969-16 | NM |
NPI | 1043571458 |
---|---|
Provider Name | Mark Himes |
First Address | Farmington, NM 87401-6589 |
Second Address | Farmington, NM 87401-6590 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2012 |
Last Update Date | 06/04/2017 |