Healthcare Provider Details

I. General information

NPI: 1245720457
Provider Name (Legal Business Name): JAREN LAGRECA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST STE 101
FARMINGTON NM
87401-8990
US

IV. Provider business mailing address

2300 E 30TH ST STE 101
FARMINGTON NM
87401-8990
US

V. Phone/Fax

Practice location:
  • Phone: 505-208-6280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD2024-0791
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: