Basic Information
| Provider Information | |||||||||
| NPI: | 1477557460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHOSHYOMN | ||||||||
| FirstName: | MANI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 LOUISIANA BLVD NE | ||||||||
| Address2: | STE 401 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871107020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052604300 | ||||||||
| FaxNumber: | 5052604338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 CENTRAL AVE SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058411234 | ||||||||
| FaxNumber: | 5058411956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD2004-0591 | NM | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 879702 | 05 | AZ | MEDICAID | 88615 | 05 | NM | MEDICAID | NM009S99 | 01 | NM | BLUE CROSS BLUE SHEILD | OTHER | 66585376 | 05 | NM | MEDICAID | 376101 | 01 | NM | PRONET / AETNA | OTHER |