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Individual

MIRANDA C HALEY

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
M.D.

Contact information

Practice address
117 CAMINO DE VIDA, SUITE 300, SANTA ROSA, NM 88435-2267
(575) 472-4311
Mailing address
PO BOX 26666, PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770

Taxonomy

Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD2014-0107
NM

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
96507021
NM
Enumeration date
06/22/2011
Last updated
08/13/2019
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