Basic Information
| Provider Information | |||||||||
| NPI: | 1811330434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINNEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | REGINALD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 435 SAINT MICHAELS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059133450 | ||||||||
| FaxNumber: | 5059133451 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 SAINT MICHAELS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059133450 | ||||||||
| FaxNumber: | 5059133451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2013 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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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 | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD2015-0667 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.