Healthcare Provider Details

I. General information

NPI: 1003065749
Provider Name (Legal Business Name): MARTIN NICHOLAS ANCONA PHD, MP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 ANTHONY DR STE B
ANTHONY NM
88021-9190
US

IV. Provider business mailing address

224 ANTHONY DR STE B
ANTHONY NM
88021-9190
US

V. Phone/Fax

Practice location:
  • Phone: 575-489-8999
  • Fax: 575-205-0068
Mailing address:
  • Phone: 575-489-8999
  • Fax: 575-205-0068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number0040C
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1296
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY60201752
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: