Healthcare Provider Details

I. General information

NPI: 1073455945
Provider Name (Legal Business Name): XAN ASMODEUS GARZA CCHW SPECIALIST 1
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2026
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 GARRISON RD
LAS CRUCES NM
88001-5706
US

IV. Provider business mailing address

2130 GARRISON RD
LAS CRUCES NM
88001-5706
US

V. Phone/Fax

Practice location:
  • Phone: 575-915-4059
  • Fax:
Mailing address:
  • Phone: 575-915-4059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberS1-2015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: