Basic Information
| Provider Information | |||||||||
| NPI: | 1093796815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DOM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH-FASSLER | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DOM, RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | SUITE 222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 JEFFERSON ST NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871092136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059257464 | ||||||||
| FaxNumber: | 5059254579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 07/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | 679 | NM | Y | Other Service Providers | Acupuncturist |
No ID Information.