Healthcare Provider Details

I. General information

NPI: 1902405442
Provider Name (Legal Business Name): LAUREN ELISE PINCOMB APODACA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2020
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 1/2 BURKE RD
LAS CRUCES NM
88007-5012
US

IV. Provider business mailing address

2325 1/2 BURKE RD
LAS CRUCES NM
88007-5012
US

V. Phone/Fax

Practice location:
  • Phone: 575-932-8167
  • Fax:
Mailing address:
  • Phone: 575-932-8167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2022-0123
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: