Basic Information
| Provider Information | |||||||||
| NPI: | 1205892940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANAS | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | RNCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4316 CARLISLE BLVD NE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871074829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058372100 | ||||||||
| FaxNumber: | 5058887943 | ||||||||
| Practice Location | |||||||||
| Address1: | 4316 CARLISLE BLVD NE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871074829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058372100 | ||||||||
| FaxNumber: | 5058887943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | R25559 | NM | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.