Facts
- Status
- A
- Credential
- PT
- Type
- Individual
- Enumeration date
- 2025-10-13
- Last updated
- 2025-10-13
Licenses
- License TX
- 1406857
- License NM
- PT-2025-0244
- License TX
- 1406857
- License NM
- PT-2025-0244
Location
- Practice location
- 2404 S LOCUST ST STE 5
- City
- LAS CRUCES NM
- Postal code
- 880015789
- Phone
- 575-521-4188
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.