Basic Information
Provider Information | |||||||||
NPI: | 1972869949 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PATZ | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | DANDY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6210 | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 874996210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5056092258 | ||||||||
FaxNumber: | 5056092259 | ||||||||
Practice Location | |||||||||
Address1: | 1010 THREE SPRINGS BLVD | ||||||||
Address2: |   | ||||||||
City: | DURANGO | ||||||||
State: | CO | ||||||||
PostalCode: | 813018296 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9707643207 | ||||||||
FaxNumber: | 9707643789 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2012 | ||||||||
LastUpdateDate: | 05/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 0057087 | CO | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | S52152425 | MA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.