Provider Demographics
NPI:1225564800
Name:BOKOLISHVILI, MARIAM H (SA)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:H
Last Name:BOKOLISHVILI
Suffix:
Gender:F
Credentials:SA
Other - Prefix:
Other - First Name:MARIAM
Other - Middle Name:
Other - Last Name:BOKOLISHVILI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, SA
Mailing Address - Street 1:1511 W ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1746
Mailing Address - Country:US
Mailing Address - Phone:505-459-3988
Mailing Address - Fax:
Practice Address - Street 1:1511 W ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1746
Practice Address - Country:US
Practice Address - Phone:505-459-3988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
15-489246ZC0007X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant