Basic Information
Provider Information | |||||||||
NPI: | 1801962485 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEAD | ||||||||
FirstName: | BONNIE | ||||||||
MiddleName: | KAY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PYKE | ||||||||
OtherFirstName: | BONNIE | ||||||||
OtherMiddleName: | KAY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 128 MARKET ST | ||||||||
Address2: |   | ||||||||
City: | ALAMOSA | ||||||||
State: | CO | ||||||||
PostalCode: | 811012290 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195895161 | ||||||||
FaxNumber: | 7195895722 | ||||||||
Practice Location | |||||||||
Address1: | 106 BLANCA AVE STE 300 | ||||||||
Address2: |   | ||||||||
City: | ALAMOSA | ||||||||
State: | CO | ||||||||
PostalCode: | 811012340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195893658 | ||||||||
FaxNumber: | 7195899514 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/27/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 43240 | CO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.