Provider Demographics
NPI:1861693137
Name:WALES, NATHAN A (DOM)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:A
Last Name:WALES
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2370 CAMINO MELITON
Mailing Address - Street 2:APT A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507
Mailing Address - Country:US
Mailing Address - Phone:505-470-5705
Mailing Address - Fax:
Practice Address - Street 1:1660 OLD PECOS TRL
Practice Address - Street 2:SUITE H
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4779
Practice Address - Country:US
Practice Address - Phone:505-470-5705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM926171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist