Basic Information
| Provider Information | |||||||||
| NPI: | 1205893864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN WILLIGEN | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAMERTSFELDER | ||||||||
| OtherFirstName: | DEBRA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1397A WEIMER ROAD | ||||||||
| Address2: | PO BOX DD | ||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057588883 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1397A WEIMER ROAD | ||||||||
| Address2: | HOLY CROSS HOSPITAL | ||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057588883 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 95-58 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.