Healthcare Provider Details

I. General information

NPI: 1104455286
Provider Name (Legal Business Name): NEW MEXICO STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 COLLEGE DRIVE
LAS CRUCES NM
88003
US

IV. Provider business mailing address

P.O. BOX 30003 MSC 3AE
LAS CRUCES NM
88003
US

V. Phone/Fax

Practice location:
  • Phone: 575-646-2034
  • Fax:
Mailing address:
  • Phone: 575-646-2034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: LUCINDA BANEGAS-CARREON
Title or Position: EXTENSION ASSOCIATE II
Credential: M.P.H., CHES
Phone: 575-646-2034