Healthcare Provider Details

I. General information

NPI: 1134628563
Provider Name (Legal Business Name): VICTOR LEE ILOG FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6202 ALCHEMY ST
LAS CRUCES NM
88012-0850
US

IV. Provider business mailing address

6202 ALCHEMY ST
LAS CRUCES NM
88012-0850
US

V. Phone/Fax

Practice location:
  • Phone: 575-520-2824
  • Fax:
Mailing address:
  • Phone: 575-520-2824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberG-1916
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: