Basic Information
| Provider Information | |||||||||
| NPI: | 1528526464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DHARMARAJAN | ||||||||
| FirstName: | ILANGO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | AGPCNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 465 SAINT MICHAELS DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875058602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059134710 | ||||||||
| FaxNumber: | 5059134711 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 SAINT MICHAELS DR STE 116 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059842600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2019 | ||||||||
| LastUpdateDate: | 09/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 55465 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 55465 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.