Basic Information
| Provider Information | |||||||||
| NPI: | 1447233432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NANES | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | N. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4112 OUTLOOK BLVD | ||||||||
| Address2: | SUITE 37 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810081667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195626300 | ||||||||
| FaxNumber: | 7195626376 | ||||||||
| Practice Location | |||||||||
| Address1: | 4112 OUTLOOK BLVD | ||||||||
| Address2: | SUITE 37 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810081667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195626300 | ||||||||
| FaxNumber: | 7195626376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 09/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 29956 | CO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | DR.0029956 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01299569 | 05 | CO | MEDICAID |