Individual provider · NPI-1

Mariam H Bokolishvili, S.A.

Physician Assistant, Surgical · Santa Fe, NM

NPI number1225564800
StatusActive
Last updated in NPPESMay 9, 2018

Details

NPI
1225564800
Entity type
Individual (NPI-1)
Name
Mariam H Bokolishvili
Credential
S.A.
Sex
Female
Sole proprietor
Yes
Enumeration date
May 3, 2017
Last updated
May 9, 2018

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
363AS0400X Physician Assistant, Surgical15-489–Yes
246ZC0007X Specialist/Technologist, Other, Surgical Assistant15-489–

Other names

  • Mariam Bokolishvili (Other Name)

Practice location

1511 W Alameda St
Santa Fe, NM 87501-1746

Phone 505-459-3988

Mailing address

1511 W Alameda St
Santa Fe, NM 87501-1746

Phone 505-459-3988

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