Basic Information
| Provider Information | |||||||||
| NPI: | 1568478279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOHAN | ||||||||
| FirstName: | JULIANE | ||||||||
| MiddleName: | NICHOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOHAN | ||||||||
| OtherFirstName: | JULIANE | ||||||||
| OtherMiddleName: | NICHOLE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2600 YALE BLVD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059947999 | ||||||||
| FaxNumber: | 5052430366 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 YALE BLVD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059947999 | ||||||||
| FaxNumber: | 5052430366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 10/29/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | NM 86-182 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
No ID Information.